Digital Hazards for Feeding and Eating: What We Know and What We Don

Current Psychiatry Reports (2021) 23: 56 https://doi.org/10.1007/s11920-021-01271-7 PSYCHIATRY IN THE DIGITAL AGE (J SHORE, SECTION EDITOR) Digital Hazards for Feeding and Eating: What We Know and What We Don't Konstantinos Ioannidis 1,2,3,4 & Samuel R Chamberlain 5,6 Accepted: 1 June 2021 / Published online: 15 July 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 highquality 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 This article is part of the Topical Collection on Psychiatry in the Digital Age * Konstantinos Ioannidis 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 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 considered more common and are often underdiagnosed [6]. Restrictive eating, typical of AN, is often interspersed with binge eating or purging or excessive exercise 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 56 Page 2 of 8 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 several factors are targeted simultaneously through comprehensive 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 × environment 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 particular 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 mandates led to a socio-cultural body ideal mismatch. The latter has been considered a piece of the puzzle in the gene × environment 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 communication, entertainment, and work in less than four decades, and has now shaped our lives irreversibly. While the essential and extremely 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, pornography [14•] has been associated with marked functional impairment [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 academic 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 eating disorders, as to whether specific engagement with online content would impact on the development, course and management of eating disorders across the life span. A number of observational and experimental studies were performed since in attempt to disentangle effects and described the relevant relationships [19••]. New and Interesting Findings Research in the last decade started by exploring the membership in pro-anorexia forums (consumption and engagement in Curr Psychiatry Rep (2021) 23: 56 “Pro-ANA” web-based content) [20] as those became very popular among anorexia sufferers. A few important steps towards understanding the role of PUI in ED patho (...truncated)