PSYCHIATRY IN THE DIGITAL AGE (J SHORE, SECTION EDITOR)
Digital Hazards for Feeding and Eating: What We Know
and What We Don't
Konstantinos Ioannidis1,2,3,4 & Samuel R Chamberlain5,6
Accepted: 1 June 2021
# The Author(s) 2021
Abstract
Purpose of Review We aimed to accrue recent evidence exploring effects of modern online activities (e.g., Internet use) on feeding
and eating disorder symptoms, and related traits. We examined available evidence to ascertain any direct influences from online
activities on feeding and eating disorders, thereby shedding light on putative mechanisms by which those influences may occur.
Recent Findings Many facets of problematic usage of the Internet correlate cross sectionally with eating disorder and related
psychopathology. There is evidence to suggest that significant effects do exist in the direction of specific Internet activities
contributing to eating disorder symptoms, viewed dimensionally. Putative mechanisms are discussed. However, a significant
number of eating disorder phenotypes and Internet-related activities remain under-researched.
Summary Specific facets of engagement with the online environment appear to confer risk for feeding and eating problems,
evidence being strongest for non-clinical studies using dimensional measures. More research is required to rigorously confirm
causal effects, including in patients meeting formal diagnostic criteria for eating disorders. We also highlight the need for high-
quality evidence to explore how eating disorder phenotypes are commonly as well as uniquely affected by different online
activities. Such research is needed in order that scientific understanding in this area can be translated to protect those most at risk
of disordered eating, including through changes in public health approaches and clinical practice.
Keywords Anorexia nervosa . Bulimia nervosa . Binge eating disorder . Eating disorder . Internet addiction . Social networking
site . Social media . Problematic Internet use
Introduction
Eating disorders (EDs) confer an important health burden for
societies worldwide [1, 2]. Anorexia nervosa (AN) has the
highest morbidity and mortality of all mental illnesses [3]
and a significant lifetime prevalence, depending on diagnostic
criteria and population under study [4]. Bulimia nervosa (BN),
binge eating disorder (BED) [5], and other less studied known
diagnostic categories, e.g., avoidant-restrictive food intake
disorder (ARFID), are consideredmore common and are often
underdiagnosed [6]. Restrictive eating, typical of AN, is often
interspersed with binge eating or purging or excessive exer-
cise behaviors and cross-diagnostic interplay of symptoms is
very common [7], while more often than not, individuals swap
between ED diagnostic classifications during their lifetime.
Specifically, since the introduction of Diagnostic and
Statistical Manual Version 5 (DSM-5) criteria for feeding
and eating disorders [8], the prevalence of diagnostic groups
is considered to have increased among all main diagnostic
categories [9]. Eating disorders have a complex partially
This article is part of the Topical Collection on Psychiatry in the Digital Age
* Konstantinos Ioannidis
ioannik@doctors.org.uk
1 Department of Psychiatry, University of Cambridge, Cambridge, UK
2 Cambridge and Peterborough NHS Foundation Trust,
Cambridge, UK
3 Department of International Health, Care and Public Health Research
Institute, Maastricht University, Maastricht, Netherlands
4 Eating Disorder Service, Addenbrookes Hospital, Hills Road,
Cambridge CB2 0QQ, UK
5 Department of Psychiatry, University of Southampton,
Southampton, UK
6 Southern Health NHS Foundation Trust, Southampton, UK
https://doi.org/10.1007/s11920-021-01271-7
/ Published online: 15 July 2021
Current Psychiatry Reports (2021) 23: 56
known pathophysiology which implicates multiple layers of
socio-cultural and biological contextual variables [7]. There is
paucity of experimental research in the field [10] and most
things we know about the pathophysiology of EDs derive
from “quasi-experimental” studies and randomized controlled
trials (RCTs). While RCTs include a manipulated component
that separates the intervention and the control arm, often sev-
eral factors are targeted simultaneously through comprehen-
sive treatment programs; this approach does not necessarily
allow for the identification of causal effects with adequate
enough precision to specify effects to fine detail [10]. While
we have been building our understanding of the gene × envi-
ronment interaction to identify risk factors for EDs towards
the end of the twentieth century, efforts were made through
observational research to understand the influences of popular
media (paper media, advertisements, TV) on eating disorder
risk factors. Pooled evidence suggested that women in partic-
ular are suffering from a hazardous influence from exposure to
popular media in terms of body dissatisfaction, internalization
of thinness ideals, and disordered eating [11, 12]. Exposure to
beauty ideals coupled with an internalization of media man-
dates led to a socio-cultural body ideal mismatch. The latter
has been considered a piece of the puzzle in the gene × envi-
ronment interaction driving ED pathophysiology [13].
In the 1980s, a mighty force was born: the world-wide-web. It
went from a whimsical idea to dominating real life communica-
tion, entertainment, and work in less than four decades, and has
now shaped our lives irreversibly. While the essential and ex-
tremely valuable applications of the Internet in daily life are
irrefutable, maladaptive forms of engagement with the online
environment, encompassing a variety of activities (e.g., overuse
of social media, streaming media, gaming, gambling, pornogra-
phy [14•] has been associated with marked functional impair-
ment [15, 16••]. The term problematic usage of the Internet
(PUI) was coined to describe such dysfunctional engagement
with multiple facets of Internet-based activities [16••]. PUI is
now linked with poorer health, worse social, vocational, or aca-
demic outcomes or lower quality of life [16–18]. Since 2010, and
given the previously mentioned concerning influences of media
on eating disorder outcomes, significant concern arose within
researchers, clinicians, and carers about those suffering from eat-
ing disorders, as to whether specific engagement with online
content would impact on the development, course and manage-
ment of eating disorders across the life span. A number of obser-
vational and experimental studies were performed since in at-
tempt to disentangle effects and described the relevant relation-
ships [19••].
New and Interesting Findings
Research in the last decade started by exploring the member-
ship in pro-anorexia forums (consumption and engagement in
“Pro-ANA” web-based content) [20] as those became very
popular among anorexia sufferers. A few important steps to-
wards understanding the role of PUI in ED pathophysiology
were made, when Facebook use was found to prospectively
predict an increase in drive for thinness 2 years later [21••],
whereas receiving negative feedback through Facebook inter-
actions was found to negatively associate with disordered eat-
ing attitudes [22]. Social networking site (SNS) use also pre-
dicted an increase in body dissatisfaction [23]. These results
supported a causal hypothesis of the role that social media
may have in eating disorders. However, such effects of SNS
on EDwere not identified in other studies [24]. Being exposed
to pro-ED content or “fitspiration” content (media content
aimed to inspire towards fitness activity or a fit body ideal)
or regular popular social media (which often contain dieting,
fitness, or other-appearance-focused content) as opposed to
neutral conditions (e.g., viewing travel images or spending
time reading encyclopedia entries online) seems to bear a de-
gree of risk towards the development of mood and self-esteem
difficulties that fuels EDs. Those experimental conditions
were tested to show the “PUI condition” associating stronger
with lower appearance self-esteem [25] and higher ED symp-
tomatology [26–29]; those with appearance comparison traits
were more prone to low mood effects from exposure to social
media [30, 31] . Another important aspect of engaging with
the online content is the exposure to manipulated content, as
this has the potential of creating unrealistic expectations of
appearance and beauty. Under experimental conditions, self-
photo editing led to increased negative mood and body (facial)
dissatisfaction, with higher levels of editing leading to more
dissatisfaction. Furthermore, enhancement-free images seem
to have less effect on body dissatisfaction, suggesting that
self-photo manipulation may be playing a role in body dissat-
isfaction effects [32•, 33]. While PUI × EDs interactions have
been more explored in adult participants under experimental
conditions, AN and BN are considered to sometimes have
their beginnings in adolescence or earlier in life. The effects
of appearance-focused gaming vs. ED-neutral gaming were
assessed in young girls: those exposed to appearance-
focused gaming had higher body dissatisfaction [34•]. This
essentially represents a form of replication work from physical
world experiments to the online environment; pre-pubertal
girls exposed to Barbie doll play have high internalized thin
ideals [35] and reduced food intake [36]; appearance-focused
online gaming may influence EDs through a mechanistically
similar fashion. This is a critically important point while on-
line gaming in children and adolescents is growing as a cul-
tural norm in developed societies, in which EDs are also more
prevalent.
While activity tracking apps and fitness apps have become
very popular among the eating disorder community, problem-
atic usage of the Internet was shown to partially mediate the
relationship between sensation-seeking impulsivity and eating
56    Page 2 of 8 Curr Psychiatry Rep (2021) 23: 56
disorders with high exercise levels [37]. Additionally, prob-
lematic usage of the Internet was found to partially mediate
the link between obsessionality and eating disorders with high
exercise levels [37]. Usage of fitness and calorie-tracking apps
has correlated with eating disorder and related psychopathol-
ogy both in males and females [38–40]. It is possible that in
the background of particular latent traits of impulsivity or
obsessionality/compulsivity, exposure to calorie or fitness
apps may trigger problematic behaviors (e.g., excessive exer-
cise) and potentially contribute to the development of clinical-
ly significant levels of ED in those who are vulnerable.
However, those are outcomes of online surveys with various
methodological limitations and disallow the drawing of any
causal inferences.
Another developing area of interest has been the investiga-
tion of how dating sites may be influencing eating disorder
and related psychopathology. Dating sites put emphasis on
physical appearance and sharing of image-based content. As
such, the individual is invited to judge others by their image
while eliciting judgment on themselves. By creating this con-
tent, the individual engages in a process known as self-
objectification [41]; however, self-objectification may also
occur in other forms of social and popular media. Self-
objectification is moderately correlated with disordered eating
in meta-analysis (Pearson’s r = 0.39, 53 cross-sectional stud-
ies), with larger effect sizes identified in females [42••].
Dating sites use has been cross sectionally associated with
eating disorder symptomatology in various quantitative and
qualitative studies [43–46].
A less well-understood aspect of engagement with the on-
line environment is the one in which the user is subjected to
harassment behavior, also known as cyberbullying.
Experiencing cyberbullying through social media is consid-
ered to have not only debilitating effects on mental health in
general [47], but also significant correlations with body dis-
satisfaction, negative body perception, and lower self-esteem
[48, 49]. The culture of body shaming has sparked a heated
debate around whether such an approach can be deemed haz-
ardous for the obesity population as it may well be for the
eating disorder populations [50]. A quasi-experimental field
study showed that fat-shaming events on social media could
have putative snowball effects on the anti-fat attitudes in the
wider population, the effects increasing with the notoriety of
the event [51]. Body shaming can masquerade as essential
public health messaging or as an essential component in the
coach-athlete relationship [52], but essentially may constitute
a form of emotional maltreatment [52]. While cyberbullying
constitutes a form of maltreatment occurring in the online
environment, it is possible that its effects may be detrimental
for the individual’s global mental health, rather than being ED
specific. However, experiencing body shaming, regardless of
whether the individual is victimized themselves in the event or
not, may have specific effects on self-apprehension of weight,
shape, or appearance, body dissatisfaction, or foster unhelpful
anti-fat attitudes, which may be strong precursors for the de-
velopment of EDs. Furthermore, it may promote stigma to-
wards EDs, which can hinder the likelihood of affected indi-
viduals accessing timely help, and/or engaging fully with
treatment, thereby worsening clinical outcomes [53]. For
males, it may be even worse, as they need to battle against
toxic masculinity and a well-established societal stigma (also
present in the medical community) which promotes stereo-
types of gender and sexual orientation in relation to those
suffering from EDs.
Trends and Developments
While a substantial portion of the quantitative literature sup-
ports the notion that significant positive correlations exist be-
tween various facets of PUI and eating disorder and related
psychopathology [19], those observational studies have fo-
cused on either precursor risk factors for eating disorders
(e.g., the thin-ideal internalization, appearance comparisons,
perfectionistic personality traits, loneliness, socio-cultural
body ideal mismatch, self-objectification) or eating disorder
symptoms which, on their own merits, do not necessarily con-
stitute clinically significant levels of formal mental health dis-
order (e.g., body dissatisfaction, drive for thinness, dietary
restraint, drive for muscularity) (see Figure 1).
Equally important is the fact that many of those personality
dimensions, risk factors, and symptoms are trans-diagnostic, e.g.,
perfectionism is common not only in AN but also in obsessive
compulsive personality disorder; e.g., body dissatisfaction and
drive for muscularity are common not only in EDs (mainly AN
and BN) but also in body dysmorphic disorder. Thin-ideal inter-
nalization (ITI) is common in AN and BN. The trans-diagnostic
nature of those symptoms, together with a paucity of clinical-
level ascertainment in the literature, does not yet provide the
necessary confidence to rigorously confirm causality between
hazardous levels of PUI and occurrence of formal EDs. It is
furthermore unclear how different facets of EDwould be impact-
ed differentially; thus, specific PUI behaviors like consumption
of “thinspiration” content via SNS might be hazardous towards
AN or BN outcomes, while other ED categories, e.g., BED or
ARFID, where there is less presence of ITI may not be affected.
Furthermore, cyberbullying victimization may affect differential-
ly patients at higher BMIs (e.g., BED sufferers) through experi-
ences of body shaming, or those who struggle to comprehend
nuances of the online media social context (e.g., those who may
have AN and autistic spectrum disorder comorbidity or other
deficits in their theory of mind) and might be more vulnerable
to cyber-harassment.
Moreover, it is less understood how some of the clinical
phenotypes of ED are related to PUI. An interesting case se-
ries of ARFID and Internet gaming disorder (IGD)
Page 3 of 8     56Curr Psychiatry Rep (2021) 23: 56
comorbidity was published [54] suggesting that both ARFID
and IGD manifesting as coping strategies (a method of emo-
tional regulation) to those avoidant of emotional distress. The
relationship between Internet gaming and EDs is less under-
stood, but there are examples in which body shaming and
fatness have been used in video games to associate the obese
male or female body with evilness, disability, monstrosity,
and horror [55]. Such games are played by hundreds of mil-
lion users worldwide and have the potential of having a sub-
stantial influence in the socio-cultural attitudes towards obese
body types, potentially adding to weight-related stigma [56].
Finally, research has explored how the digital medium can be
used to potentially promote a healthier body image; for example,
an experimental study showed exposure to parody images of
thin-ideal celebrities was associated with higher body satisfac-
tion, when compared to exposure to the actual thin-ideal image
[57]; self-disclaimers show little effectiveness in altering body
image influences [58]. Further research is warranted to further
understand how technology can be harnessed to promote a
healthy relationship with someone’s own body, nutrition, and
exercise. Identification of vulnerable populations (e.g., via
algorithmic/machine learning approaches, with appropriately rig-
orous statistical methodologies including cross-validation and
independent replication) seems to be an important first step,
which can then be followed by targeted ED-specific resilience
promoting content. Apps, podcasts, and health resources already
exist aiming to promote ED recovery to those seeking digital
solutions to treatment and online delivery of psychotherapy has
become the new norm during the COVID-19 pandemic.
Most of those processes are currently at a preliminary
stage, including how they can translate to real life appli-
cations, notwithstanding the major ethical considerations
relevant to this process that involve, but not exhaustively,
privacy, confidentially, and informed consent.
Insights
While the online environment continues to advance in many
profound but also intricate ways, research attention has shifted
to other facets of engagement with the online milieu, including,
but not exhaustively, the consumption of image-based content
through social media and image-based gaming, and even more
recently the utilization of fitness-tracking/calorie-tracking appli-
cations (Apps), dietingApps, datingApps, andmukbang stream-
ing consumption (mukbang is further explained below). A recent
meta-analysis supported the fact that a variety of PUI facets are
important for the understanding of digital hazards for feeding and
eating [19]. Critically, while SNS have been relatively better
studied, the use of activity and fitness tracking Apps, calorie-
tracking Apps, and dating Apps, as well as cyberbullying expe-
riences, may be playing a role in the link between PUI and eating
disorder and related psychopathology.
Controversy and Debate
Another growing trend has been the investigation towards the
understanding of mukbang as an emerging online behavior since
2014. Mukbang (“muk-bang” or “meokbang”) is a Korean port-
manteau term for “eating broadcast” and usually involves a host
preparing and eating typically large amounts of food, while lei-
surely interacting with an audience in an online streaming plat-
form. By some self-reports, mukbang has been regarded to have
both beneficial (e.g., preventing binge eating episodes, reducing
loneliness) and negative sequalae (triggering restrained eating or
loss of control over eating) on eating disorder symptoms [59•]. It
is possible that mukbang may be a fun, leisure, and intimate
experience for a large portion of the population; millions engage
with the streaming content daily and professional mukbang
Fig. 1 Example illustration of the relationship between multiple facets of Internet usage and risk factors, precursors for feeding and eating disorders, as
well as eating disorder symptoms
56    Page 4 of 8 Curr Psychiatry Rep (2021) 23: 56
streaming is reportedly very profitable for the individual. On the
other hand, it may create a platform for patients with AN to
engage with food without consuming it, thus missing out on
essential nutrition leading to self-neglect, or trigger binging epi-
sodes with untoward consequences [60]. It is a well-known fact
that ED sufferers, even those at very low BMIs (e.g., AN), are
“food lovers” and are generally much more fascinated by food
preparation and consumption as compared to the general popu-
lation. Thus, the fact that mukbang viewing is positively corre-
lated with EDs is not a surprise [61], particularly when the ob-
served behaviors are not ascertained at a maladaptive or clinical
level. Anecdotal reports suggest that on occasionmukbang view-
ing promotes recovery practices [62]; therefore, it is still debat-
able whether consuming mukbang is a problematic behavior.
Greater research-driven understanding is needed before any caus-
al links are drawn; in approaching the mukbang phenomenon in
a confirmatory and atheoretical fashion, we risk
overpathologizing the behavior, an existing risk in behavioral
addictions research in general [63].
Conclusion
We have discussed here specific facets of engagement with
the online environment bear risk for feeding and eating prob-
lems viewed largely using dimensional measures in non-
clinical settings. Experimental and prospective studies support
a potential causal role for the engagement with social media
leading to higher levels of body dissatisfaction and internali-
zation of the thin ideal. The role of self-objectification, appear-
ance comparison, impulsivity/compulsivity, or the socio-
cultural body ideal mismatch is relatively unexplored from a
mechanistic perspective, particularly in terms of the interac-
tion of those concepts with a variety of relatively distinct on-
line behaviors (e.g., consumption of pro-ED content, calorie-
tracking/fitness apps, dating sites, gaming, mukbang stream-
ing or watching, experiencing cyberbullying victimization).
More longitudinal and experimental research is required to
ascertain specific effects, simulating conditions of the various
aspects of potentially hazardous online engagement towards
the potential development of eating disorder psychopathology
and to further clarify how research findings can best be trans-
lated into public health and clinical arenas (e.g., see Table 1),
in order to optimally protect those who are vulnerable to de-
veloping disordered eating symptoms, or experiencing exac-
erbations thereof.
Acknowledgements We are indebted to all the researchers and health
workforce who have supported ourselves and our society during these
testing times.
Funding Dr Chamberlain’s involvement in this research was funded by a
Wellcome Trust Clinical Fellowship (110049/Z/15/Z). Dr Chamberlain
previously consulted for Promentis. He receives stipends from Elsevier
for journal editorial work. Authors received no funding for the prepara-
tion of this manuscript. The other authors report no financial relationships
with commercial interest relevant to the content of this manuscript.
Declarations
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
Table 1 Problematic usage of the
Internet and eating disorders, and
preliminary recommendations for
public health and clinical care
Preliminary recommendations for public health and clinical care
Public health Clinical care
Promotion of discussion between stakeholders in
regards to whether potentially hazardous online
content should be regulated; and if so, how
Dissemination of scientific findings into the public
domain by appropriate communication, including
raising awareness that potentially hazardous
content, may contribute towards the development of
eating and feeding disorders
ED-orientated health advice (e.g., ED-helpline, local
services access) and supportive messaging to be
recommended on image-based online
platforms/content to encourage early help seeking
for people with EDs
Public advice for families caring for sufferers of ED,
also experiencing PUI in their home environment
Public debate on medical and other considerations
relevant for the application of ED-specific resilience
building online content (digital medicine/digital
public health interventions)
Clinician awareness of how the Internet (including
PUI) is clinically relevant to understanding and
treating EDs, including in eating disorder clinics
(e.g., redaction of problematic Internet usage may
be considered as complementary psychotherapeutic
target for those receiving help for their eating
disorder together with other established treatment
goals)
Consideration of screening for eating disorders in
newly developing clinics of problematic usage of
the Internet (e.g., online gaming), particularly if
overuse of social media is present
Awareness that EDs often coexist with other disorders,
including those that can be contributed to by PUI.
Exploration of Internet-related vulnerabilities (e.g.,
overuse of social media, overconsumption of fitness
Apps/“fitspiration” content) as part of routine ED
clinical practice
Page 5 of 8     56Curr Psychiatry Rep (2021) 23: 56
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Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
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