Introduction

Body image concerns and eating disorders are the most pervasive health problems in emerging adults [1]. Eating disorders are severe mental disorders; they can become chronic and are associated with the high mortality rates [2]. Therefore, the analysis factors that help to explain the etiology of disordered eating is of great importance.

Sociocultural models are the dominant explanatory models of how sociocultural influences affect women’s and men’s body images. A dominant framework is the tripartite influence model (TIM) [3]. This model states that associations between the perceived sociocultural pressures from family, peers, and the media and disordered eating are mediated by thin and/or low fat/muscular body ideal internalization and body dissatisfaction. The internalization of societal beauty standards refers to the adoption of socially defined ideals as a personal standard in a way that can affect attitudes and behavior [3]. Originally developed in the US, the TIM has been replicated in Western Europe, Australia, and in some Asian and Arab countries [3,4,5,6,7,8,9,10,11]. Although the model is largely supported in various cultures some important differences have been found suggesting different practical implications for body image concerns prevention programs in various cultural contexts [5, 6, 8, 11,12,13].

Nevertheless, TIM has never been explored in Lithuanian samples. Lithuania is undergoing rapid sociocultural transformations promoting body image in mass media [14]. However, body image concerns and obesity are prevalent among young adults [15, 16]. Replication of the TIM is important since it will add empirical evidence for the development effective and culturally sensitive body image concerns prevention and/or obesity treatment programs. Currently, body image concerns and disordered eating prevention programs are in infant stage in educational settings of Lithuania. Therefore, the present study aimed to fill this gap.

The prevalence of overweight and obesity is rising worldwide [17]. There is evidence that overweight young people experience greater pressure over their appearance, body dissatisfaction, and restrained eating than do their counterparts of normal body weight [18, 19]. Although body dissatisfaction risk factors are common among young people of various body weights, overweight and obese youth may face a unique set of sociocultural pressures that amplify their body image dissatisfaction. Weight-related teasing and bullying are more prevalent among overweight youths compared with their siblings of healthy weight [20]. As a result, overweight and obese youths can find it difficult to form supportive social relationships with their peers and can demonstrate lower psychosocial health. Longitudinal studies have shown that body dissatisfaction is associated with an increase in BMI over time [21]. While body dissatisfaction may lead to less healthy outcomes among young people who are overweight or obese, it is important to understand the complex nature of sociocultural factors that influence the development of body dissatisfaction in these youths. Surprisingly, we found no evidence in the literature of applying the TIM framework to young overweight and/or obese students (male and female). Doing so could help to shape prevention programs intended to reduce the body image concerns of overweight and obese students of either gender.

Studies have demonstrated that women typically internalize the thin ideal [11], while men’s internalization is more complex and associated with a muscular/athletic body image with low body fat [22,23,24]. Internalization of a low body fat ideal in men is associated with muscle-building behaviors such as weight training, drinking proteins, and using other muscle gain-related substances [25]. Some of these behaviors are healthy but others, such as the use of anabolic steroids, are not and can lead to eating disorders [22, 23] or muscle dysmorphia [26]. Studies have shown that dissatisfaction with muscularity and body fat represent dual body-image pathways to men’s engagement in muscle enhancement and disordered eating behaviors [22]. On the basis of previous studies, we therefore, included the drive for muscularity in the TIM for men [8, 24].

The general aim of the present study was to test the TIM among Lithuanian students of healthy body weight (women and men separately), with the expectation of replicating it. Particularly, we expected that associations between the perceived sociocultural pressures from family, peers and the media and disordered eating will be mediated by thin and/or low fat/muscular body ideal internalization and body dissatisfaction. Second, we aimed to test the TIM on overweight/obese students of both genders. No specific assumptions were developed for the second aim of the present study.

Methods

Participants

A mixed-gender sample (n = 1850) of undergraduate (n = 1641; 88.7%) and graduate (n = 209; 11.3%) students from various Lithuanian state universities and colleges participated in this study. The sample consisted of (n = 763; 41.2%) male and (n = 1087; 58.8%) female students who were enrolled on natural and agricultural (6.6%), technology (38.0%), medical and health (27.5%), social and humanities (27.3%), study areas. 0.6% (n = 11) of the study participants did not indicate their study area. The mean age of men was 20.4 (SD = 3.1) years, of women 22.4 (SD = 5.8) years.

Procedure

Eleven universities and four colleges participated. As part of a more extensive study, the students completed online, self-report questionnaires measuring sociocultural influences on their body image, body image, quality of life, self-esteem, and body mass index (BMI). They completed the battery of questionnaires during scheduled class time, with no imposed time limit. 1,941 questionnaires were received, from which 56 individuals refused to participate in the survey (response rate was 97.1%). The final study sample of 1,850 participants provided all the information necessary for statistical analysis. For the data collection, an online questionnaire was used, and the final sample contained no missing data.

Measures

Demographic data Participants were asked to specify their gender, age, education at university or college, study program, and course.

Body mass index (BMI) was calculated in kg/m2 from students’ self-reported height and weight. Students' BMI was classified into four body mass categories: underweight (BMI < 18.5 kg/m2), normal weight (BMI = 18.5–24.9 kg/m2), overweight (BMI = 25.0–29.9 kg/m2), and obese (BMI ≥ 30.0 kg/m2) [27]. The majority of the sample (70.3% of men and 72.7% of women) were of normal weight (BMI ranged from 14.0 to 47.3 (M = 22.7, SD = 3.7) kg/m2). The results showed that 21.9% of men and 12.8% of women were overweight, and 3.9% and 4.2%, respectively, obese. In further analyses, the overweight and obesity categories were combined; and 10.3% (n = 112) of the women and 3.9% (n = 30) of men who were underweight were excluded.

The Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) [28] is a 22-item, self‐report instrument designed to assess the general role of sociocultural influences on body image and appearance-related internalization. The SATAQ-4 comprises five subscales, each composed of items rated on a 5-point Likert scale where 1 means definite disagreement and 5 definite agreement. The higher the score, the greater the acceptance or internalization of dominant sociocultural standards of appearance. The thin/low body fat internalization subscale reveals individuals’ preferences for a slim body; the muscular/athletic internalization subscale assesses how much respondents believe that they should look muscular and athletic; the family pressure subscale measures family members' pressure on respondents to meet dominant sociocultural standards of appearance; the peer pressure subscale assesses the extent to which respondents feel pressure from their friends and peers to conform to social expectations of appearance; and finally, the media pressure subscale measures how much respondents feel pressure from the media to conform to socially valued ideals of body appearance. The Lithuanian version of the SATAQ-4 has demonstrated good validity and reliability in a student population sample [29]. In the present sample, Cronbach’s α’s for the SATAQ-4 were as follows: thin/low body fat, 0.91; muscular/athletic, 0.88; family pressure, 0.90; peer pressure, 0.93; media pressure, 0.98; and total SATAQ-4, 0.91.

The Lithuanian version of the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS) [30] was used to assess the appearance-related elements of the body image construct. This instrument of 34 items consists of five subscales, with responses captured on a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree). The appearance evaluation subscale gauges perceptions of physical attractiveness; the appearance orientation subscale reveals the degree of investment in one’s appearance; the overweight preoccupation subscale evaluates weight vigilance, dieting, fat anxiety, and eating restraint; and the body area satisfaction subscale assesses satisfaction or dissatisfaction with particular areas of the body. The Lithuanian version of the MBSRQ-AS has demonstrated good validity and reliability in a student population sample [31]. In the present study, Cronbach’s α for the appearance evaluation, appearance orientation, overweight preoccupation, and body area satisfaction subscales was 0.83, 0.79, 0.73, and 0.88, respectively.

The Lithuanian version of the Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0) [32] is a 28-item, self‐report questionnaire designed to comprehensively evaluate the essential behavioral characteristics of EDs and eating disordered behavior. The EDE-Q 6.0 concentrates on the last 28 days and establishes two models of data. First, the six open-ended questions yield frequency data on the essential behavioral characteristics of EDs (in terms of the number of episodes of the behavior or number of days on which the action occurred): objective binge eating, self-induced vomiting, laxative use, and excessive exercise. Second, 22 attitudinal questions across four subscales produce subscale scores reflecting the severity of the ED characteristics. Responses are recorded on a 7-point Likert scale from 0 (no day) to 6 (every day), with higher scores reflecting greater severity or higher frequency. The Lithuanian version of the EDE-Q 6.0 (LT-EDE-Q 6.0) has demonstrated good validity and reliability in a student population sample [33]. In the present study, Cronbach’s α for the LT-EDE-Q 6.0 general scale was good (0.94).

We used the Drive for Muscularity Scale (DMS) [34] to examine behaviours reflecting preoccupation with muscularity. The scale assesses individuals’ perceptions of not being muscular enough and of needing to add bulk to their body frame in the form of muscle mass (irrespective of their percentage of actual muscle mass or body fat). It consists of 15 items rated a on 6-point scale ranging from 1 (never) to 6 (always). Higher scores indicate more muscle development behaviors. Psychometric properties of the Lithuanian version of the DMS were good [35]. In the present study, the internal consistency of the scale was good (Cronbach α = 0.89).

The Lithuanian version of Rosenberg’s Self-Esteem Scale (RSES) [36] was used to assess self-esteem and general feelings of self-worth. The scale is composed of 10 items scored on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Higher scores denote higher self-esteem. The RSES is the most widely used measure of global self-esteem. The tool demonstrated good internal consistency in the present study with a Cronbach’s α of 0.89.

Statistical analysis

The internal consistency of the scales was tested using Cronbach’s α. Mediation analysis was conducted using AMOS version 24 (Analysis of Momentary Structure, SPSS; Armonk, NY: IBM Corp.) with 2000 bootstrap samples to estimate the size of the total, direct, and indirect effects and to provide 95% confidence intervals (CIs) for each effect. The significance of the direct, indirect, and total effects was assessed with chi-square tests, and the significance of the mediational paths was further confirmed through the bootstrap resampling method, with 2000 bootstrap samples and 95% bias-corrected CIs: effects were considered significant (p < 0.05) if zero did not appear in the interval between the lower and the upper limits of the CIs. Using the continuously varying sample size approach to Monte Carlo power analysis approximately 150 individuals are required to ensure statistical power is at least 80% for detecting the hypothesized indirect effect [37]. The goodness of fit of the models was assessed using various good fit values: goodness of fit index, GFI (0.95 < GFI < 1.00); the adjusted goodness of fit index, AGFI (0.90 < AGFI < 0.95); the comparative fit index, CFI (0.95 < CFI < 1.00); the Tucker Lewis Index, TLI (0.95 < TLI < 1.00); and the root of the mean square error of approximation, RMSEA (0.00 < RMSEA < 0.05 = good fit; 0.05 < RMSEA < 0.08 = acceptable fit).

Results

A series of path analyses were conducted. The resulting path coefficients between thin body ideal and body image for the young men with normal body mass and between muscular body ideal and body image for the young women were not statistically significant. Thus, further models were run separately for the men with normal body mass and the overweight/obese women subsamples. The models generated for the women of normal body weight and for those who were overweight replicated the original TIM model, and in the final step one model for both groups was presented. As different body image-representing subscales predominated in the male and female groups, the mediation effects between perceived pressure, ideal body internalization, various body image aspects, and disordered eating behaviors were tested. The characteristics of the fit of the final models are presented in Table 1.

Table 1 Fit of the path models in a student sample (n = 1704)
Full size table

The final model for the young women (Fig. 1) accounted for 18% of the thin body ideal, 28% of appearance evaluation, 41% of overweight preoccupation, 26% of body area satisfaction, and 66% of disordered eating behaviors. The model showed high goodness-of-fit indices (Table 1). Perceived pressure from family, peers, and the media in these young women directly predicted internalization of the thin body ideal. Likewise, internalization of the thin body ideal positively predicted preoccupation with being overweight, with a direct effect of 0.55 (b = 0.44; SE = 0.021; Z = 20.81; p < 0.001). Also, preoccupation with being overweight had a positive effect of 0.38 on disordered eating behaviors (b = 0.50; SE = 0.033; Z = 15.30; p < 0.001). Conversely, internalization of the thin body ideal negatively predicted appearance evaluation and body area satisfaction. A higher level of body and appearance satisfaction were associated with reduced risk of disordered eating behaviors. Analysis of the indirect effects revealed mediating effects of perceived pressure on body image and disordered eating behaviors (Appendix Table 2). Finally, internalization of the thin body ideal mediated the effect between perceived media pressure and body image in these women.

Fig. 1
figure 1

Final path model, women (n = 975). Standardized path coefficients are presented; *p < 0.05

Full size image

The resulting model for the young men with normal body mass (Fig. 2) accounted for 4% of the muscular/athletic body ideal, 15% of the drive for muscularity, 19% of appearance orientation, and 19% of disordered eating behaviors. Furthermore, the model showed high goodness-of-fit indices (Table 1). Perceived pressure from family and the media had no effect on these young men’s internalization of the muscular/athletic body ideal; however, perceived pressure from peers did, with an effect of 0.19 (b = 0.22; SE = 0.048; Z = 4.59; p < 0.001), as did drive for muscularity with an effect of 0.13 (b = 0.168; SE = 0.052; Z = 3.24; p = 0.001). Next, internalization of the muscular/athletic body ideal affected the drive for muscularity with an effect of 0.32 (b = 0.36; SE = 0.045; Z = 7.94; p < 0.001). On the other hand, internalization of the muscular/athletic body ideal positively predicted appearance orientation. In addition, appearance orientation had a positive effect of 0.12 on disordered eating behaviors (b = 0.15; SE = 0.05; Z = 2.89; p = 0.004). Internalization of the muscular body ideal and the drive for muscularity were also positively associated with increased disordered eating risk. However, higher levels of self-esteem had a protective effect of − 0.11 on the drive for muscularity (b = − 0.022; SE = 0.008; Z = − 2.67; p = 0.008) and of − 0.17 on disordered eating behaviors (b = − 0.02; SE = 0.005; Z = − 4.21; p < 0.001). Analysis of indirect effects revealed a mediating effect of internalization of the muscular body ideal on disordered eating behaviors (Appendix Table 3). Higher levels of self-esteem were also found to have an indirect protective effect on disordered eating. Finally, perceived pressure from peers had indirect effects on appearance orientation and disordered eating in these men of normal body mass.

Fig. 2
figure 2

Final path model, men with normal body mass index (n = 536). Standardized path coefficients are presented; *p < 0.05

Full size image

The final model for overweight and/or obese male students included all three measured perceived pressures, internalization of the thin and muscular body ideal, and body image effects on disordered eating behaviors (Fig. 3). The model accounted for 9% of the internalization of the thin body ideal, 44% of the internalization of the muscular body ideal, 40% of preoccupation with being overweight, 30% of appearance evaluation, 18% of the drive for muscularity, and 56% of disordered eating behaviors. The model presented satisfactory goodness-of-fit indices (Table 1). Perceived pressure from peers among these overweight/obese male students directly predicted internalization of the thin body ideal, whereas direct family and peer pressure effects were not significant. Internalization of the thin/low body fat body ideal predicted internalization of the muscular/athletic body ideal, with a direct effect of 0.67 (b = 0.71; SE = 0.058; Z = 12.21; p < 0.001). Internalization of the thin body ideal was positively associated with preoccupation with being overweight and negatively predicted appearance evaluation, with the effect of − 0.55 (b = − 0.40; SE = 0.06; Z = − 6.75; p < 0.001). On the other hand, internalization of the muscular/athletic body ideal had a direct effect on the drive for muscularity of 0.42 (b = 0.46; SE = 0.071; Z = 6.45; p < 0.001) and on appearance evaluation of 0.49 (b = 0.34; SE = 0.055; Z = 6.12; p < 0.001). In addition, higher levels of appearance satisfaction were associated with lower risk of disordered eating behaviors (β = − 0.32; b = − 0.47; SE = 0.077; Z = − 6.13; p < 0.001), whereas preoccupation with being overweight increased the risk of disordered eating (β = 0.42; b = 0.56; SE = 0.076; Z = 4.44; p < 0.001). The drive for muscularity effect on disordered eating behaviors was not significant. Analysis of indirect effects revealed mediated effects of perceived family pressure on body image and disordered eating behaviors (Appendix Table 4), while internalization of the thin body ideal mediated the effect of perceived pressure from peers on internalization of the muscular body ideal, body image, and disordered eating behaviors. The effect of perceived pressure from the media on the drive for muscularity was mediated by internalization of the muscular body ideal. Finally, appearance evaluation mediated the effect of internalization of the muscular/athletic body ideal on disordered eating in these overweight and obese male students.

Fig. 3
figure 3

Final path model, men with overweight and obesity (n = 193). Standardized path coefficients are presented; *p < 0.05

Full size image

Discussion

The aim of the present study was to test the TIM on a sample of healthy weight students (women and men separately), expecting to replicate the original model. For healthy weight women, original TIM was replicated and the final model explained 66 percent of the variance in disordered eating. These findings are in line with those of other studies [7]. The most powerful predictor of internalization of the thin ideal was pressure from the media. This finding coincides with other studies reporting that pressure from the media is the mostly significant predictor of body dissatisfaction in women [38]. Internalization of the muscular ideal did not emerge in the TIM for the women. This finding is in line with the studies showing that internalization of the athletic ideal does not act as a mediator in the relationship between sociocultural influences and body dissatisfaction in women [39]. The path model for the overweight and obese women replicated the original model as well. Thus, these results suggest that body image concerns and disordered eating prevention programs might be similar in content as for Western women.

For healthy body weight men, the original model was not fully replicated. Neither pressure from family nor that from the media was significant in our study. Nor did we find a significant pathway between sociocultural pressure and internalization of the thin/low fat ideal in this group of young men. The strongest sociocultural pressure in the TIM was that from peers. Other studies have also reported pressure from peers to be an important variable in the etiology of emotional eating [40, 41]. Further, it was found no significant associations between sociocultural pressures and body dissatisfaction mediated by internalization of the thin ideal [6]. These findings suggest different pathways in the development of men’s disordered eating in our sample to those reported in Western samples [22, 26]. The present study demonstrated that internalization of muscular/athletic ideal, appearance evaluation and drive for muscularity are mediators between peers’ pressure and disordered eating in healthy weight men. These findings are in line with those of other studies demonstrating an association between internalization of the muscular ideal, the drive for muscularity, and disordered eating in men [24, 26, 42].

However, for the overweight male students, internalization of both the thin and the muscular ideal emerged in the model. Internalization of the thin/low body fat and muscular/athletic ideals and body image concerns mediated the associations between pressures and disordered eating. Important finding is that the path of sociocultural pressure (peers) worked first through internalization of the thin ideal and then internalization of the muscular ideal. Importantly, no opposite path was observed. Pressure from peers was the strongest predictor of thin/low fat ideal internalization. It might be explained by greater weight – related teasing and bullying that is more prevalent among overweight youths compared to their siblings of normal weight [20]. Preoccupation with being overweight and poorer appearance evaluation, but not the drive for muscularity, mediated associations between the internalization of thin/low body fat/ muscular/athletic ideals and disordered eating. It should be mentioned that not all behaviors listed on the drive for muscularity scale are damaging to health; some of them might even be recommended for overweight men. Internalization of the athletic ideal is likely to require a balanced diet and exercise aimed at achieving and sustaining lean body mass. Therefore, promotion of the muscular ideal combined with education about positive body image and healthy nutrition may result in the uptake of healthier lifestyle practices by overweight young men [39]. However, these findings are new and future studies might usefully focus on attempting to replicate our results.

Our findings suggest that intervention programs designed to prevent or treat body image concerns in women of different BMI might usefully consider including media literacy education together with cognitive dissonance induction approaches, as has been found to be effective with Western samples [43,44,45]. However, for young men of healthy body weight, lowering internalization of the muscular ideal, the drive for muscularity, and teaching them to strive for functional, not only appearance- related body features should be the target of education. In contrast, for overweight men, promoting the athletic ideal, reducing internalization of the thin ideal, preoccupation with being overweight, and increasing body satisfaction may help to prevent disordered eating and to promote healthier lifestyles.

Several limitations should be considered when interpreting the findings of this study. Partner and/or friend pressures as meditational variables were not included in the model. Other studies have found these to be important variables in the etiology of body image concerns and disordered eating [22, 23]. Nor was appearance comparison included in the model. While some studies have reported this not to be influential in predicting men’s dissatisfaction with their muscularity, others have found it important for the development of women’s body images [46]. Another limitation of the present study is its cross-sectional design, which prevents any causal interpretations being made concerning the model’s variables. Self-reported anthropometric measures might also be the limitation of the present study. Finally, the sexual identity of the sample may be important in explaining associations between sociocultural pressures and disordered eating [7, 23]. Future studies should address these issues.

Conclusions

The original TIM was replicated in Lithuanian women of different BMI. For men of healthy body weight, the associations between peers’ pressures and disordered eating were mediated by internalization of muscular/athletic ideal, drive for muscularity and investment towards appearance. For overweight men, original TIM was replicated, however, internalization of muscular/athletic ideals and greater appearance evaluation mediated the associations between media pressures and disordered eating.

What is already known on this subject?

The tripartite influence model of body dissatisfaction and disordered eating states that the associations between the perceived sociocultural pressures and disordered eating are mediated by thin and/or low fat/muscular body ideal internalization and body dissatisfaction. Although the model is largely supported in various cultures some important differences have been found suggesting different practical implications for body image concerns prevention programs in various cultural contexts.

What does this study add?

TIM was replicated for the large sample of Lithuanian young women of various body weights suggesting that the prevention of disordered eating might be similar to this of Western women. However, TIM was not fully replicated for men of healthy body weight suggesting that internalization of the thin ideal is not relevant. Lowering internalization of the muscular ideal, the drive for muscularity, investment towards appearance and teaching to resist peer’s pressures might be the effective targets of disordered eating prevention programs in men of healthy body weights. For overweight men, increasing the resistance to peers’ pressures, reducing internalization of the thin appearance ideals and preoccupation with being overweight, may help to prevent disordered eating. Further, increasing greater appearance evaluation might help to prevent disordered eating in overweight men who internalize muscular/athletic ideals.