Over the past half century, there has been a steady and sinister rise in the prevalence of eating disorders. In the United States alone, thirty million men and women will develop a clinically significant eating disorder at some point in their lifetime (Wade, Keski-Rahkonen, & Hudson, 2011). Because eating disorders boast the highest mortality rate of any psychiatric condition and are often comorbid with other psychiatric disorders, it is essential to understand relevant risk factors in order to reduce their impact on susceptible populations (Arcelus, Mitchell, Wales, & Nielsen, 2011). While eating disorders have traditionally been considered mental disorders stemming from a persistent disturbance in body image, there is a growing body of psychological research suggesting that eating disorders are, at least in part, an internal manifestation of a larger social problem. The sociocultural model points to the development of an eating disorder as a longitudinal effect of the internalization of a media-portrayed “thin ideal,” the cumulative product of body dissatisfaction, negative affect, and dieting behavior. As body image dissatisfaction prevails as the most supported predictor of eating disorder onset, it follows that this relationship is a dangerous one to mediate. Paralleling the escalation of disordered eating symptoms and body dissatisfaction is the growing preeminence of mass media. Although the existing eating disorder literature covers etiological factors from genetics to personality, this review will focus on the detrimental role of the media in the form of commercial advertisements, social networking platforms, and pro-anorexia websites in creating and proliferating an incubator for eating disorder development, as well as highlight potential interventions to create a more positive media influence. Although the development of an eating disorder is complex and unique to the individual, understanding and combating the influence of the media could prove a powerful tool for prevention and treatment, as media is one of the few modifiable risk factors.
The Role of Print Media
America is the epitome of a consumer culture, flooded with media imagery mandating how one should best dress, live, and look. Despite the tremendous variation in body shape between individuals, the fashion industry champions the tall and thin. The average American woman is 5'4”, weighing 140-150 pounds with a dress size of 12-14; the average high fashion model is at least 5'9” and weighs 110 pounds. Fifty years ago, fashion models were less than 10% thinner than the average woman; today, they are nearly 25% thinner (Bloomfield-Deal, 2015). The Social Comparison Theory provides an appropriate framework for understanding how idealized media images can be internalized and integrated into disordered eating schemas. Leon Festinger posited that humans possess a fundamental drive to “evaluate his opinions and his abilities,” comparing the self to others as a means of identity exploration (Festinger, 1954). Especially with respect to Western women, there exists a prevailing and problematic expectation to conform to the feminine ideal. This form of upward comparison proves dangerous when the object of comparison is a digitally altered, airbrushed version of the original, making the pursuit for perfection even more unattainable. Thompson, Coovert, and Stormer (1999) strengthened this connection, finding that appearance-based evaluations mediate the relationship between social feedback, body image, and subsequent eating pathology. Multiple studies have underscored the speed at which these evaluations are made, showing that even when disclaimer labels or pre-exposure alteration messages are provided, viewing of thin-ideal advertisements still resulted in social comparison and increased body dissatisfaction (Bury, Tiggemann, & Slater, 2017).
While adolescent and young adult populations are the most avid consumers of media and also the most at-risk for developing an eating disorder, studies have been conducted assessing the relationship between media consumption and eating disorder symptomology on a wide range of age groups. A study examining commercial media in a preadolescent context found that in a sample of five-to-eight-year-old girls, viewing music videos and appearance-centered magazines led to increased dieting awareness. Additionally, girls' perceptions of their peers' body dissatisfaction predicted their own level of body dissatisfaction and dieting awareness (Dohnt & Tiggemann, 2006). These results highlight the emergence of an appearance-based schema long before clinically relevant body image disturbances occur, as well as the influence of advertising on the most impressionable members of society. A community cohort consisting of girls aged 12-21 found that those who reported “frequently reading girls' magazines or listening to radio programs” were twice as likely to develop a clinically significant eating disorder (Martínez-González et al., 2003). Stice, Mazotti, Krebs, and Martin (1998) found that among a sample of 16-19-year-old females, pressure to be thin and internalization of a thin-ideal were both longitudinal predictors of dieting. Additionally, body dissatisfaction stemming from such internalization contributed to increased dieting over a nine-month follow-up period. These results reinforce that body image dissatisfaction is neither a transient nor trivial experience, but rather one that has the potential to develop into serious deteriorations in self-image and self-care. A longitudinal study of undergraduate women found that exposure to the thin-ideal was a predictor for compulsive exercise, dieting behavior, and body dissatisfaction (Homan, 2010).
Though eating disorders are more prevalent among females than males, media-determined body image ideals are not limited to females. Compiling data from the ten most popular magazines read by young women and men respectively, researchers found that the women's magazines contained greater than ten times more endorsements and features for diet and weight loss programs compared to the men's magazines. Drawing on the fact that eating disorders are roughly ten times more prevalent in females than males, this finding suggests a potential dose-response relationship between media promotion of thinness and the development of eating disorders in a given population (Andersen & DiDomenico, 1992). Review of magazine content found that over the past thirty years, the amount of partially nude men featured has exponentially increased. In addition, male action figures have become increasingly more muscular since the 1960s. This male muscular ideal has become a source of tension for men striving to achieve the ever-unattainable figure, likely contributing to the rise of body dissatisfaction, over-exercising, and steroid use by males (Strother, Lemberg, Stanford, & Turberville, 2012). Aubrey and Taylor (2009) found that men who viewed magazine ads promoting the thin ideal exhibited greater performance anxiety and associated over-exercise than those who viewed neutral magazine content. The researchers theorized that men experience a parallel feeling of anxiety because they are attempting to measure up to the women who can never measure up to the model-mandated standard, creating a vicious cycle of disordered eating and exercise patterns.
The Role of Social Media
Though the existing literature on exposure to traditional forms of media and resulting body image concerns is abundant, of paramount interest among researchers and clinicians is the relationship between social media use and the onset of disordered eating. Social media networks have become a nearly universal ubiquity, with 90% of young adults in America using at least one form of social network. (Pew Research Center, 2013). Social media presents an interesting situation; though the users themselves are featured as opposed to the models-only mandate of commercial media, the images posted to social media are often an idealized and filtered highlight reel. Moreover, perceived social media popularity has become a form of social currency, with the number of “likes” one receives serving as a measure of self-worth. While many have debated a chicken-or-the-egg scenario, the relationship between social media use and body dissatisfaction has not been shown to work in reverse. Social media use has consistently predicted negative body image, but those with negative body image are no more likely to use social media than those with healthy body image (Fardouly & Vartanian, 2016).
A cross-sectional survey of young adults found that participants in the highest quartile of social media volume and frequency (including Facebook, Twitter, Google+, YouTube, LinkedIn, Instagram, Pinterest, Tumblr, Vine, Snapchat, and Reddit) were more than twice as likely to have eating concerns significant on the Eating Disorder Screen for Primary Care compared to those in the lowest quartile (Sidani, Shensa, Hoffman, Hanmer, & Primack, 2016). A similar survey studying the association between adolescent Facebook use and body image concern found that among a sample of freshman and sophomore girls, those who used Facebook showed significantly higher on all measures related to body image concern than non-users. The amount of time spent on Facebook was positively correlated with thin ideal internalization, body-checking (a common eating disorder behavior), and resultant desire to be thin (Tiggemann & Slater, 2013). Another study investigating the role of Facebook use in eating disorders complied survey data from 960 women regarding Facebook usage and disordered eating behaviors. Those who used Facebook more frequently reported greater disordered eating, and Facebook maintained a stronger correlation with weight concerns and anxiety than did an alternative internet site (Mabe, Forney, & Keel, 2014). Zooming in on the positive correlations found between general Facebook use and body image, Kim and Chock (2015) sought to highlight specific activities that contribute to body concerns. A cross-sectional survey of college students found that “social grooming behaviors” such as liking, commenting, or sending messages to other profiles on online media was strongly associated with a drive for thinness for both genders.
Though pro-anorexia and “fitspiration” tags have technically been banned since 2012, content seeking attention for and encouraging self-destructive behavior is as prolific as ever. The instant feedback social media sites enable so easily become a double-edged sword, the “likes” those struggling with eating disorders get on photos glorifying their emaciated states serving as positive reinforcement of negative behavior (Daca, 2013). Pinterest, a popular image-based media sharing website, has been scrutinized as an instigator and sustainer of negative body image, social comparison, and destructive eating and exercise habits. A study at a large Midwestern university found that the number of “fitspiration” related Pinterest boards followed was strongly associated with user intentions to mimic advertised behaviors. In concurrence, promotion of a single ideal body type was a strong determinant of the extent to which Pinners compared their bodies to those displayed on the Pins (LeWallen & Behm-Morawitz, 2016). A 2010 experiment endeavored to assess the impact of pro-anorexia websites among a sample of female undergraduates with a healthy BMI and no eating disorder history. After viewing 1.5 hours of media content, the group exposed to pro-ED sites exhibited a significant decrease in caloric intake, with many participants reporting use of restriction tactics from the websites (Jett, LaPorte, & Wanchisn, 2010). If an isolated experience with pro-eating disorder content produced such marked emotional and behavioral changes, it is logical that constant inundation with diet and exercise propaganda on internet posts could create a culture where eating disorders flourish. A survey of 1575 females found that those who frequently visited pro-anorexia websites reported higher levels of body dissatisfaction and subsequent eating disturbances than those who did not, suggesting an association between viewership and eating disorder symptomology (Harper, Sperry, & Thompson, 2008).
The Role of Body-Positive Media
Social media is not going anywhere anytime soon. Therefore, the task at hand is to combat the deleterious effects of print and social media with empowering messages encouraging body acceptance. Since eating disorder etiology is multifaceted and often attributable to both individual and social factors, efforts have been undertaken at both levels to modify the influence of media imagery.
At the individual level, self-compassion, or the mindful turning of understanding and acceptance inward, has been suggested as an attenuating factor for media-mediated body shame. A recent analysis revealed that higher levels of self-compassion functioned as a protective factor against the association between body shame and anti-fat attitudes among a weight-diverse sample of female undergraduates (Webb, Fiery, & Jafari, 2016). Ferreira, Pinto-Gouveia, and Duarte (2013) and Kelly, Vimalakanthan, and Miller (2014) also showed that while external shame predicted the internal drive for thinness, the strength of the association between BMI and disordered eating weakens as self-compassion increases. Therefore, external pressures to be thin have the potential to be muted as internal resiliency grows. This suggests a direction for future advocacy efforts, replacing the thin-ideal monopoly with a more inclusive and attainable feminist-ideal. A 2013 experiment compared the body image ideals held by women who each viewed thin and healthy weight models. After viewing the healthy weight images, the participants held significantly larger body ideals (Owen & Spencer, 2013). While similar primary interventions aimed at increasing media literacy among vulnerable adolescent populations did result in knowledge gains, the programs did not contribute to any meaningful changes in body image or eating attitudes. It seems that such interventions are effective in decreasing internalization of the thin ideal and perceived reality of mass media images, but less so for combating body anxiety and positive associations with thinness. Researchers speculate that rejection of appearance-based media is not enough (Thompson & Heinberg, 1999). The messages that a woman's role is to be beautiful, that the size of one's waistline and one's success are inversely related, that it is part of being a woman to bemoan one's body are reinforced by parents, teachers, and peers. Successful shifting of body image schemas will require a societal-scale rejection of the single “feminine ideal” in favor of a multifaceted mindset.
It is necessary, therefore, to consider population-level public health interventions to potentiate the effects of bolstering the individual. Social marketing, hardly a new phenomenon in the world of consumer behavior, has become increasingly relevant with respect to the eating disorder community. At the most general level, social marketing attempts to enact a change in behavior among a certain specific audience. This can include sending media messages that recognize and attempt to fulfill “the need for non-body related avenues of success for women” (Thompson & Heinberg, 1999). A multi-method study at The University of Alabama at Birmingham found that participation in an online patient community supplied direct benefits to participants, including empowerment-boosting information and desired social support (Johnston, Worrell, Gangi, & Wasko, 2013). These results imply that utilizing the social support and empowerment aspects of social media can serve to improve health outcomes for a diverse range of diagnoses. A large online survey endeavored to determine the effectiveness of the Dutch website Proud2Bme, a popular community for those suffering or recovering from an eating disorder intended to serve as a positive substitute for pro-ana websites. Visiting Proud2Bme was positively associated with feeling informed, and to a lesser extent with seeking help, trusting one's treatment team, and feeling optimistic about one's recovery outcome. Further analysis found that the amusement and social support aspects of the community, suggesting that the interaction component, the “you are not alone” factor, is one that is invaluable to users (Aardoom, Dingemans, Boogaard, & Van Furth, 2014). In response to the fitspiration community, those recovering from eating disorders have popularized tags to advocate and connect with others. The tags #edrecovery and #prorecovery currently boast 2.9 and 1.1 million posts on Instagram, respectively. Kinsaul, Curtin, Bazzani, and Martz (2014) conducted multiple regression analyses on data from an undergraduate sample regarding the influence of feminist ideals, empowerment, and self-efficacy on body image and disordered eating behavior. Results showed that both promotion of a feminist ideology and self-efficacy were strong predictors of positive body image and decreased eating pathology. While the mass media currently promotes restrictive eating and compulsive dieting as accepted and encouraged practices, it also remains the primary information source about eating disorders (Peroutsi & Gonidakis, 2011). As such, an effort must be made to curtail the insidious omnipresence of diet culture in favor of a dialogue encouraging body acceptance and intuitive eating.
Although the correlational and cross-sectional research to date has provided a wealth of invaluable information, there yet exists a dearth of experimental evidence delineating causality of the associations suggested. Moreover, social media is such a young phenomenon that it will likely be years before any real longitudinal effects can be determined. Moving forward, an effort should be made to direct research interest to teasing out the respective influence of eating disorder risk factors. The majority of research to date has been focused on Facebook; because platforms such as Instagram, Pinterest, and Tumblr are more image-based, they afford more image-comparison opportunities for users and therefore warrant scientific inquiry. Further, because eating disorders are a cross-cultural phenomenon, future studies should be intentional in composing diverse samples. Finally, there is a great need for eating disorder recovery advocacy in general. Though eating disorders are the most fatal of all mental disorders, they receive among the lowest in research and healthcare funding. To maximize the dollars that have been allocated, it is the responsibility of the community to use the power of social media for encouragement and empowerment rather than comparison and shame.
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