Introduction

Social media platforms have become the focal point of people’s lives with developments in technology. These platforms appear as web-based services that allow users to distribute all kinds of information in personal ways and create different interactive and online communities [1]. Adolescents are among the most enthusiastic users of social media today, especially considering that children are part of the digital generation [2]. Adolescents’ use of social media significantly increases every day [3]. While social networks provide adolescents with many opportunities and benefits, such as expanding their social connections and improving their communication and learning skills, they also bring some risks [4]. One of these risks is the emergence of addictive behavior in individuals who excessively use social media tools and applications [5]. Social media addiction is expressed as excessively using social media and having an irresistible urge to log in to social media [2]. Adolescents who are addicted to social networks often worry unnecessarily and are motivated by an uncontrollable need for input to use social media tools. According to reports, about 12% of adolescents on social networking platforms suffer from social media addiction [6].

Adolescence is an important period in which mental, physical and emotional changes, psychosocial and sexual maturity, and the development of autonomy occur [7]. Lifelong eating habits, which are a part of the lifestyle, are shaped during this period [7]. It has been reported that eating habits are affected by various factors, including social media [8]. Previous studies have revealed a strong link between the use of social media and unhealthy eating behaviors [9]. Disordered eating behaviors can cause an increased risk of developing eating disorders that have serious psychological and medical consequences [10]. Therefore, it is very important to be aware of the factors that lead to negative eating behaviors in adolescents.

Orthorexia nervosa (ON) is defined as a phenomenon characterized by an obsessive preoccupation with healthy eating and inflexibility in diet, leading to clinically significant medical or psychosocial impairments [11]. Individuals with ON have restricted eating patterns, gradually eliminating more and more foods deemed unhealthy from their diets [12]. It has been reported in the literature that increasing the frequency of social media use increases the risk of ON [13]. Accordingly, ON might emerge as an unexpected effect of attempts made on social media to raise public awareness about lifestyle and unhealthy eating habits [14]. However, the relationship between social media addiction and ON is uncertain in adolescents.

Body image refers to one’s feelings, thoughts and perceptions about one’s own body. During adolescence, adolescents try to have thinner or more muscular bodies with the desire to have an idealized male and female appearance that does not reflect reality in social media. They tend to devalue their bodies by comparing themselves with idealized bodies [15]. The internalization of beauty ideals causes individuals to guess the difference between their own bodies and causes body dissatisfaction when this ideal is not reached [16]. Body dissatisfaction is a serious public health issue because it causes a slew of negative outcomes, such as impaired emotional well-being, low self-esteem, depression symptoms and disordered eating behaviors in adolescents [16]. Numerous studies have discovered indicating evidence pointing to a connection between unhealthy eating problems and body dissatisfaction [17]. Moreover, it has been reported that perfectionist body image perception, which is emphasized through the concepts of nutrition and health on social media platforms, may cause anxiety and eating behavior disorders [18].

The inappropriate or excessive use of social media might be risky due to its subliminal implications, especially for adolescents, considering their high usage rates. Adolescents should be aware of the unforeseen repercussions of social media [8]. In this context, determining the relationship of social media addiction with eating attitude, body image and eating disorders in adolescents will be important in terms of establishing prevention and support programs for adolescents. In the literature, the number of studies on the effect of social media addiction on health is limited, and no studies were found that evaluated the relationship between social media addiction, ON and eating attitudes in adolescents. Therefore, this study was planned to evaluate the relationship between social media addiction and body image, ON, and eating attitude to determine risk factors associated with eating behavior disorder risk and ON tendency and to examine the associations between body image and related factors.

Materials and methods

Design and participants

This cross-sectional study was conducted in three high schools located in İzmir (a city in the west of Turkey) from February to May 2022. Schools were selected using cluster random sampling. Preliminary interviews were held with the relevant schools, and following the approval of the ethics committee, necessary permission was obtained from the Directorate of National Education to conduct the study in these schools. The study sample included 1232 high school-going adolescents (712 girls and 520 boys) aged between 13 and 18 years who were in grades 9 to12. Of the total sample, 29% of the participants were in 11th grade, while 28.8% were in 10th grade. The mean age was 15.7 ± 1.19 years. Of the total sample, 21.6% were overweight, and 74.8% of the adolescents had a normal body mass index (BMI). All participants in the same school and classroom were selected if they fulfilled the inclusion criteria and provided oral consent to participate.

Inclusion criteria were being between the ages of 13 and 18 years and using social media. Exclusion criteria were being aged less than 13 or more than 18 years, unwilling and/or unable to provide informed consent, and having severe acute or chronic diseases. The flow chart of the study is shown in Fig. 1. Written informed consent was obtained from the adolescents and all parents.

Fig. 1
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Study flow diagram

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Data collection

The study data were collected through a questionnaire. Students studying in the 9th, 10th, 11th and 12th grades in three schools were asked to answer the questionnaires themselves. The questionnaire form consisted of questions to determine socio-demographic characteristics (age, gender, grade, parent’s employment status and education level, monthly income of the family), eating habits and social media usage (which application or applications they use in social media, how long they use social media, how many hours they spend on social media on average per day, their frequency of reading posts about nutrition on social media, whether they believe that posts about nutrition on social media increase their level of knowledge, etc.) of adolescents. Moreover, “Social Media Addiction Scale for Adolescents” (SMASA), Body Image Scale, Eating Attitude Test (EAT-26) and ORTO-11 scale were included in the questionnaire form.

Measures

Social media addiction scale for adolescents (SMASA)

The “Social Media Addiction Scale for Adolescents,” whose validity and reliability were determined by Özgenel et al. [19], was used to evaluate adolescents’ social media addiction. The scale consists of 9 items in total. The highest score that can be obtained from the scale with a 5-point Likert-type scale (1-never, 2-rarely, 3-sometimes, 4-very often, 5-always) is 45, and the lowest score is 9. As the scores obtained from the scale increase, it shows that the social media addiction of adolescents is high, and as the score decreases, social addiction is low [19]. According to the scores obtained from the scale, adolescents' social media addiction levels were classified as low addiction (9–21 score), moderate addiction (21–33 score), and high addiction (33–45 score) [3]. The Cronbach’s alpha reliability coefficient of the scale is 0.90 [19]. In this study, the Cronbach’s alpha reliability coefficient was 0.83.

Body image scale (BIS)

BIS, originally named “Body-Cathexis Scale (BCS),” was used to evaluate adolescents’ body perceptions. This scale was developed by Paul Secord and Sidney Jurard in 1953 [20]. “Bodycathexis” refers to various feelings and degrees of satisfaction and dissatisfaction with the body. The scale was adapted into Turkish by Selim Hovardaoğlu in 1993 [21]. The scale consists of 40 items and the highest score that can be obtained from the scale is 200, and the lowest score is 40. The increase in the scores obtained from the scale indicates that the individual’s body satisfaction increases, while the decrease indicates that the satisfaction decreases [21]. As a result of the reliability analysis of the scale, Cronbach's alpha coefficient was previously found to be 0.91 [21], while this ratio was 0.94 in our study.

Eating attitude test (EAT-26)

The EAT-26 scale was used to determine the eating attitudes and behaviors of the adolescents. This scale was first developed as 40 questions in 1979 and was revised by Garner et al. [22] in 1982 and shortened to 26 questions. The validity and reliability study of the scale in Turkey was carried out by Ergüney-Okumuş et al. [23]. It was evaluated using the sum of the scores of 26 items. As the score obtained from the test increases, the degree of eating attitude disorder increases. The cut-off value for EAT-26 is 20 points. Accordingly, those who scored equal to or above 20 on the test were defined as adolescents “prone to eating behavior disorder” [23]. Garner et al. [22] indicated that the Cronbach’s alpha of this scale was 0.85 for adolescents. In this study, it was 0.85.

Orthorexia nervosa (ON)

The “Orthorexia Nervosa Scale” was developed by Donini et al. [24] as a 15-item form as the ORTO-15 to determine the level of these behaviors in individuals who are obsessed with healthy eating or have behavioral disorders in this regard. The scale was adapted into Turkish by Arusoğlu et al. [25] and shortened to become an ORTO-11 scale. In the ORTO-11 scale, some questions in the original scale were removed, and the scale was reduced from 15 to 11 questions answered on a 4-point Likert scale. The highest score that can be obtained from the scale is 44. The cut-off point is set at 27 points. Scores of 27 points and below are defined as orthorexic. Decreased scores indicate a tendency toward orthorexic behavior, while increasing scores indicate a tendency toward normal eating behavior [25]. In this study, the Cronbach’s alpha coefficient was 0.72.

Anthropometric measurements

Body weight (kg) and height (cm) were questioned based on the adolescents’ statements. Body Mass Index (BMI) was calculated using the formula “BMI = [body weight (kg)/height (m2)]”. Adolescents’ BMI z scores were determined using the WHO Anthro Plus program [26]. According to the WHO growth curves, those with a BMI z-score <  − 2 SD for age were considered “underweight,” those with a z-score ≥  − 2 SD ≤ − ≤  + 1 SD were considered “normal,” those with >  + 1 SD were considered “overweight,” and those with >  + 2 SD were considered “obese” [27].

Statistical analyses

The data were analyzed using the SPSS software for Windows (version 23.0, Chicago, IL, USA). Mean, standard deviation, median and IQR values were used as descriptive statistical methods. Categorical variables were presented as frequency (n) and percentage (%). The conformity of the data to the normal distribution was analyzed by visual (histogram and probability graphs) and analytical methods (Kolmogrow–Smirnov test). For comparisons between groups, Chi-square test was used for categorical variables, Student’s t-test was used for normally distributed variables, and the Mann–Whitney U test was used for non-normally distributed variables. In the comparison of the measurement values of three or more independent groups, normally distributed data were analyzed using the “ANOVA Test” and data that were non-normally distributed were analyzed using the “Kruskal–Wallis H Test”. Pearson correlation analysis or spearman correlation analysis was performed to evaluate the relationship between variables. Logistic regression analyses were performed to examine risk factors associated with eating behavior disorder risk and ON tendency. The fit of the logistic regression model was evaluated with the Hosmer–Lemeshow test. Multiple regression was used to examine the associations between body image and related factors. A p value < 0.05 was statistically significant, and the p value was two-sided.

Ethics

The present study was approved by the Non-Interventional Clinical Trials Ethics Committee of Izmir Katip Çelebi University (IRB number: 0540, date: 23.12.2021) and was carried out in accordance with the Declaration of Helsinki criteria.

Results

The general characteristics of participants are shown in Table 1. A total of 1232 high school students were included, of which 712 (57.8%) were girls and 520 (42.2%) were boys. The most commonly used social network sites were Instagram, WhatsApp, YouTube and Snapchat. While 49.7% of the adolescents stated that they spent 1–3 h a day on social media, 34% stated that they spent 4–6 h.

Table 1 Characteristics of study participants
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Social media addiction levels were higher in girls (20.4 ± 6.84) than in boys (17.6 ± 6.83) (p < 0.01). The body image levels of girls (127.7 ± 24.95) were significantly lower than those of boys (137.5 ± 25.24) (p < 0.01). According to EAT-26, a score above 20 indicating a high risk of developing eating disorders was found in 21.5% of girls and 12.5% of boys. Of the adolescents, 27.9% were determined to be at risk of developing ON. While the social media addiction level of 4.4% of adolescents was high, 33.5% was moderate and 62.1% was low.

Table 2 shows the differences in adolescents’ ON tendencies, eating attitudes, and body image according to their characteristics. The EAT-26 score of those who stated that they spent ≥ 7 h on social media a day was higher than those who stated that they spent < 7 h (p = 0.010). Adolescents who stated that they always/frequently read posts related to nutrition on social media had a lower ORTO-11 score and a higher EAT 26 score than those who stated that they read posts about nutrition sometimes, rarely or never (p < 0.001). The BIS scores of adolescents with low social media addiction (136.7 ± 24.93) were higher than those with high (118.8 ± 28.82) and moderate levels of social media addiction (124.7 ± 23.89) (p < 0.001). Adolescents with high social media addiction had a higher EAT-26 score [(19.5 (20.50)] than those with low [7.0 (10.00)] and moderate social media addiction [9.0 (12.00)] (p < 0.001).

Table 2 Differences in adolescents’ ON tendency, eating attitudes, and body image according to their characteristics
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There was a significant negative correlation between SMASA score and age (r = 0.060, p < 0.05), ORTO-11 score (r =  − 0.065, p < 0.05), and BIS score (r =  − 0.311, p < 0.01). A significant positive correlation was observed between the SMASA score and EAT-26 (r = 0.258, p < 0.01). There was a significant negative correlation between BIS and the EAT-26 score (r =  − 0.230, p < 0.01) and BMI (r =  − 0.100, p < 0.01) (Table 3).

Table 3 Correlations between variables
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To assess the robustness of the correlation between body image and social media addiction when controlling for potentially confounding factors (age, gender, BMI and grade), a linear regression analysis were conducted. Multiple linear regression analysis showed that higher BIS scores were associated with lower social media addiction scores (β = −0.268, p < 0.001) (Table 4).

Table 4 Multiple linear regression for assessing association between body image and related factor
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The multivariate logistic regression analysis of the factors associated with eating behavior disorder risk and ON tendency are shown in Table 5. Social media addiction was significantly associated with a greater risk of eating behavior disorder (OR: 1.07, 95% CI: 1.04–1.10) and ON tendency (OR: 1.02, 95% CI: 1.00–1.04). Low body image was associated with the risk of eating behavior disorders (OR: 0.98, 95% CI: 0.98–0.99), whereas body image was not associated with ON tendency. Adolescents who stated that they always or often read nutrition-related posts had an increased likelihood of eating behavior disorder risk (OR: 6.77, 95% CI: 3.84–11.94) and ON tendency (OR: 5.49, 95% CI: 3.39–8.88).

Table 5 Multivariate logistic regression analysis of risk factors associated with eating behavior disorder risk and ON tendency
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Discussion

This study aimed to evaluate the relationship between social media addiction and ON, eating attitude, and body image. In this study, approximately one out of every three adolescents had a moderate level of social media addiction. A study conducted in Turkey, found that a large percentage (56%) of adolescents had moderate social media addiction [3]. Similarly, Deniz et al. [28] found that high school students were moderately addicted to social media. A study conducted with adolescents in Egypt showed that 55% of adolescents had extreme social media addiction [29]. The difference in the level of social media addiction in this study from other studies can be explained by the fact that the number of samples and the evaluation scale used are different from those of other studies. In line with these results, adolescents should be in the priority group to be protected from social media addiction.

This study showed that the social media addiction level of female adolescents was higher than that of males. This finding is consistent with previous studies conducted with Philippine [8] and Turkish adolescents [30]. Doğusever et al. [30] revealed that 20% of adolescents are social media addicts (13% girls, 7% boys). In a report published by the Turkey Statistical Institution in 2019, it was reported that girls (81.8%) used the Internet more than boys (68.9%) [31]. In another study, female students studying in high school spent more time on social media than male students, and this is explained by female students’ curiosity about what is happening on social media and keeping their minds busy with social media [32]. In addition, the high use of social media among girls was associated with girls wanting to stay in touch with their friends regardless of distance [33]. There is also evidence that females are genetically more prone to addiction [3].

It has been reported that social media has effects on body image, especially in adolescents [34]. A significant correlation was found between visual posts on social media and the occurrence of risk factors, such as body image dissatisfaction, internalization of appearance ideals, urges for thinness, and dietary restrictions, which predispose people to eating disorders [34]. In the present study, multiple linear regression analysis showed that a better body image was associated with lower social media addiction (β =  − 0.268, p < 0.001). Consistent with this study, a study conducted with secondary school students found that time spent on social media was negatively associated with body image satisfaction [35]. Cohen and Blaszczynski [36], in their study of 229 female university students, indicated that the use of Facebook predicted higher body dissatisfaction [36]. Another study revealed that adolescents compared their own bodies with the bodies of others as a result of the images they were exposed to on various platforms with Internet or magazine content [37]. Supporting previous studies, in this study, most of the adolescents had access to visual-based platforms such as Instagram, WhatsApp, YouTube and Snapchat, which led them to share and watch photos or videos of peers and celebrities. With the prolonged use of these social media platforms, adolescents may begin to compare themselves to others, which may lead to the development of a negative body image. Taken together, these results suggest that the use of social media has an effective role in adolescents’ thoughts about body appearance and body perception.

In this study, multivarite regression demonstrated that a greater risk of eating behavior disorders was associated with higher social media addiction and lower body image. The results of previous studies support these findings [8, 24, 38]. Tadena et al. [8] revealed that social media affinity was associated with negative eating attitudes among Philippine adolescents. In another study, adolescents compared their physical appearance with others on social media, and this was as risky as comparing physical appearance in real life in terms of developing a negative eating attitude [38]. Repeated exposure to thin-ideal internalization via social media affinity has been identified as a significant risk factor for eating disorders and body dissatisfaction [24]. Although the main cause of eating disorders is unknown, it may be caused by a combination of biological, developmental, cultural, psychological, familial or environmental factors. Additionally, the definition of beauty as a thin body can cause illusions in body image and an increase in eating disorders every day [39]. A strong relationship between body image and eating attitude in this study supports this hypothesis. Rodgers et al. [40] reported that social media addiction, which focuses on appearance, is associated with increased eating disorders. Similarly, another study showed that social media, particularly platforms with a strong focus on posting and viewing images, are associated with an increase in eating disorders in young adolescents [41]. Supporting these results, in this study, adolescents used platforms where images were widely used. These results suggest that deterioration in eating attitudes may occur due to the exposure of adolescents to social media applications, various visuals and magazine items on the internet. At the same time, there may be deterioration in eating behaviors to reach the body image they desire to have.

With the widespread use of social media, it has become easier for people to access information about healthy nutrition. However, as a result of factors such as the different interpretations of this easily accessible information and the existence of unproven information, healthy eating thoughts and behaviors can become obsessive in people, which may lead to the emergence of ON [34]. In this study, as social media addiction increased, the tendency toward ON increased. Studies in this area in the literature are quite limited and to the best of our knowledge, it is the first study to specifically examine the relationship between adolescents’ social media usage characteristics and ON tendencies. Similar to our study, the ON tendency was 1.37 times higher in social media addicts among nurse and doctor candidates [42]. In addition, in the study of Klassen et al. [43] evaluated the relationship between social media and nutrition outcomes and revealed that adults were influenced by the healthy recipes they saw on social media [43]. An online study with adult women found that higher Instagram use was associated with a tendency toward ON [13]. Instagram’s features of sharing food photos and following desired people expose people to certain images on a regular basis. When healthy eating is shared by influencer on Instagram, these shares reportedly affect individuals [13].

The relationship of ON with social media addiction is explained by the fact that social media use triggers many different mechanisms in individuals, such as social appearance anxiety, body image, self-concern and eating attitude [44]. The strong correlation between eating attitudes and ON in this study supports this hypothesis. However, no relationship was found between body image and ON. Consistent with this result, Kardaş [45] found that body image was not associated with ON in university students. In contrast, Barnes and Caltabiano [46] found that excessive preoccupation with weight and high scores on the body image scale were predictors of ON. In addition, it has been emphasized that individuals prone to ON have very rigid thoughts not only about healthy eating but also about a healthy body image. This difference between our study and the literature can be attributed to the fact that the sample size of the study and the ratio of adolescents diagnosed with ON are different from other studies.

Adolescents, who meet their needs for news, education, culture and entertainment with social media, also follow the content in the field of nutrition with interest [2]. While social media allows individuals who do not know about nutrition to communicate with large communities in a wide area, it makes it difficult for them to grasp that the information shared is accurate, reliable and based on science [47]. On digital platforms, famous people who have the opportunity to convey messages to large audiences and who do not have sufficient knowledge on the subject provide false, misleading and potentially harmful advice using online resources [48]. In this study, adolescents who read nutrition-related posts frequently had a higher risk of eating behavior disorder and ON tendencies. Similarly, in a study conducted in secondary school students, the use of the Internet and social networks for content related to eating behaviors was associated with inappropriate eating attitudes/behaviors, binge eating, vomiting and laxative/diuretic use [35]. In a study conducted with adults in Turkey, individuals with negative eating attitude behaviors followed nutrition topics more often on social media [49]. Sharing about nutrition in social media, which is a fast, important and effective tool in obtaining information, can be effective in developing behavior change in individuals [49]. In this study, the high ON tendencies of the adolescents who stated that they frequently followed nutrition-related posts on social media suggested that eating attitude and health perception might have been affected by the use of social media. These results reveal the necessity of providing cooperation between health professionals and influencers to reduce nutrition-related misinformation that may occur in social media.

This study demonstrated that the risk of developing ON is higher in girls than boys. The gender difference in ON distribution is debatable. Some studies have revealed no significant gender differences in ON [14, 50], or have shown a higher prevalence among males [24, 51]. However, in several studies, ON was found to be more common in females, which is consistent with the present study [12, 52]. The increased prevalence of ON among females supported the hypothesis of a possible relationship between ON and autism spectrum disorder (ASD) [12]. Being female and reporting higher autistic traits were statistically predictive factors for the presence of ON [53]. Some authors have reported the presence of a possible link between ON and female phenotypes of ASD [12]. ON was also thought to be associated with other psychopathological characteristics, such as obsessive–compulsive spectrum, repetitive behaviors, and perfectionism traits [54]. These findings suggest that ON should be regarded as a condition with clinical significance and not simply a behavioral/lifestyle phenomenon. Moreover, while ON may be linked to psychopathological dimensions and ASD, these links are not yet clear and should be investigated further.

This study has some limitations. First, the cross-sectional design of this study limited the ability to make causal inferences. Second, data were obtained through self-reporting, which may lead to false reporting and recall bias due to the nature of the study. Third, this study sample included adolescents studying at 3 high schools in Izmir, so these results cannot be generalized. Fourth, ORTO-11 form which is adapted from ORTO-15, was used to determine the level of orthorexic behavior. However, questionnaires from the ORTO-family have been criticized for their lack of reliability, low psychometric properties and unstable factorial structure and low adherence to ON symptoms [55].

Conclusion

This study demonstrated that social media addiction was associated with a higher eating behavior disorder risk, ON tendency and lower body image. Moreover, frequent reading of posts about nutrition on social media was positively associated with ON tendency and eating behavior risk. These results highlight that adolescents should be educated about social media use and its content to minimize the negative effects of constant exposure to unrealistic body images and nutrition-related misinformation and reduce the risk of eating disorders and ON among adolescents.

What is already known on this subject?

Numerous studies have discovered evidence pointing to a connection between unhealthy eating problems and body dissatisfaction. Moreover, the presence of a relationship between use of social media and body image saticfiction has already been revealed in the literature. Additionally, previous studies have shown that social media addiction is associated with negative eating attitudes. However, no study was found that evaluated the relationship between social media addiction, ON and eating attitudes in adolescents. This study is important in terms of establishing prevention and support programs regarding social media addiction for adolescents.

What does this study adds?

This study showed that social media addiction was associated with a higher eating behavior disorder risk and ON tendency among adolescents. In addition, the findings of this study support prior studies indicating that social media usage increases the risk of body dissatisfaction. Additionally, the results demonstrated that frequently reading posts about nutrition on social media was positively associated with ON tendency and eating behavior risk. These results suggest that adolescents should be educated about social media use and its content to minimize the negative effects of constant exposure to unrealistic body images and nutrition-related misinformation.