The use of internet sources for nutritional information is linked to weight perception and disordered eating in young adolescents

Abstract

The internet serves as an accessible and confidential resource for young adolescents seeking nutritional information. However, the quality of information retrieved online is mixed and could have serious implications for users. Young adolescents who perceive themselves as overweight may be disproportionately affected as they are at greater risk for disordered eating. The current study aimed to (1) assess whether the frequency of use of different internet sources to obtain nutritional information differs between healthy weight young adolescents and those with overweight/obesity based on both objective and perceived weight status and (2) evaluate the relationships between different internet sources utilized for nutritional information and disordered eating. Young adolescents (n = 167; 10–15 years) completed the Children's Eating Attitudes Test (ChEAT; total disordered eating), indicated their perceived weight status, and reported how often they obtained nutritional information from the following internet sources: professional websites, personal websites, social media, commercial weight loss websites, and forums. Objective height and weight measurements were obtained. Young adolescents that perceived themselves to be a little overweight or overweight reported greater use of personal websites (p = .012), commercial weight loss websites (p = .011), and social media (p = .019) for nutritional information than those that did not perceive themselves to be a little overweight or overweight. The frequency of use of internet sources for nutritional information did not differ based on objective weight status. Greater use of each of the internet sources for nutritional information was related to greater disordered eating (p's < 0.05). While longitudinal research is needed to further examine these relationships, healthcare providers and teachers should provide young adolescents with guidance for interpreting and using online nutritional information to encourage valid and reliable health recommendations.

Introduction

Internet usage among children and adolescents has exponentially increased in recent years. In the United States, 95% of adolescents have access to the internet via smartphone and 45% report that they are online almost constantly (Anderson & Jiang, 2018). Studies reveal that 31–84% of youth report seeking general health information online (Ghaddar, Valerio, Garcia, & Hansen, 2012; Lenhart, Purcell, Smith, & Zickuhr, 2010; Wartella, Rideout, Montague, Beaudoin-Ryan, & Lauricella, 2016). Over time, increased access and reliance on the internet will likely result in even greater use of the internet for health information by adolescents.

Adolescents are most likely to use a search engine when seeking health information and usually select one of the first nine results (Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005). This may be because youth report that the vast number of search results make it difficult to determine credibility (Gray et al., 2005). One study found that 50% of adolescent participants selected the first result without searching any further (Wartella et al., 2016). However, the internet is an attractive means for obtaining health information for youth for reasons beyond accessibility. Adolescents value confidentiality when discussing health-related topics, especially in the healthcare environment (Britto, Tivorsak, & Slap, 2010; Rutishauser, Esslinger, Bond, & Sennhauser, 2003; Schaeuble, Haglund, & Vukovich, 2010). Many adolescents report concerns about their medical providers sharing their health information with their parents and/or other providers and are therefore reluctant to use medical providers as resources for obtaining health information (Britto et al., 2010; Rutishauser et al., 2003). Further, some adolescents perceive that medical providers do not take teen health concerns seriously (Jacobson, Richardson, Parry-Langdon, & Donovan, 2001). The internet allows youth to seek information on sensitive health issues anonymously rather than discussing these issues with medical providers (Gray et al., 2005; Lenhart et al., 2010). Similarly, youth are likely to turn to the internet to supplement the information they received at school, from family members, or from their peers (Wartella et al., 2016); this is especially true as youth report that the health content taught in their schools is censored or not comprehensive enough (Gray, Klein, Cantrill, & Noyce, 2002).

Adolescent internet users commonly seek information on various health topics including diet, fitness, exercise, sexual behaviors, sexually transmitted diseases, birth control, and skin conditions (Borzekowski & Rickert, 2001; Ettel, Nathanson, Ettel, Wilson, & Meola, 2012). Wartella et al. (2016) found that fitness and nutritional information were the two most commonly searched health topics among adolescents. There is a substantial amount of nutritional and fitness online content shared via blogs, social media platforms, forums, etc. (Saperstein, Atkinson, & Gold, 2007). However, the quality of health information retrieved online is mixed and could have serious implications for youth users making behavioral health modifications.

Previous research suggests that the source of the website is likely associated with the quality and credibility of its health information (Hirasawa et al., 2013; Modave, Shokar, Peñaranda, & Nguyen, 2014; Ostry, Young, & Hughes, 2007). Websites of designated health organizations (e.g., Mayo Clinic, National Institutes of Health) tend to contain information that is more accurate and evidence-based than websites from other sources (Cline & Haynes, 2001; Hirasawa et al., 2013; Ostry et al., 2007). However, these sites may be more likely to present information in blocks of text and utilize fewer visual and interactive elements, which are preferred by youth internet users (Reen, Muirhead, & Langdon, 2019). Further, medical, government, and university websites infrequently are included in the top results when individuals use a search engine to search for weight loss content (Modave et al., 2014).

While content presented on forums, social media, and blogs might be more engaging and visually appealing, the websites are often authored by individuals without medical or health professional experience and are unregulated (Cline & Haynes, 2001; Culver, Gerr, & Frumkin, 1997). Therefore, they frequently contain messages that are inconsistent with standard medical practices and recommendations (Cline & Haynes, 2001; Culver et al., 1997; Scanfeld, Scanfeld, & Larson, 2010). Content analyses of nutritional websites reveal that many “healthy lifestyle” and “inspirational fitness” (i.e., “fitspiration”) websites promote unhealthy eating behaviors and attitudes including dieting, dietary restraint, guilt inducing messages, and problematic eating (Boepple & Thompson, 2014, 2016). In addition, there are a considerable number of websites that promote anorexia nervosa, commonly referred to as “pro-ana sites”, which are frequently viewed by adolescents. One study found that 9.7% of the adolescents sampled had been exposed to a pro-ana site (Custers & Van den Bulck, 2009). Thematic content analyses of these websites yielded common themes of control, success, and perfection and many of these sites also encourage the use of weight-loss pharmaceuticals (Custers & Van den Bulck, 2009; Fox, Ward, & O'Rourke, 2005; Norris, Boydell, Pinhas, & Katzman, 2006). Peebles et al. (2012) found that use of these pro-ana sites was associated with greater disordered eating behaviors and poorer quality of life. Despite these troubling findings about the quality of online nutritional information, most teens report that they trust the credibility of the health content they retrieve online (Ettel et al., 2012). Many youth report changing their health behaviors as a result of what they read online, but research is lacking on whether these alterations are healthy or unhealthy (Ettel et al., 2012; Wartella et al., 2016).

Children and adolescents may be disproportionately affected by the potential negative implications of internet use for health information as they are at greater risk for disordered eating than adults. Further, there is evidence to support that youth with overweight or obesity are at increased risk for disordered eating compared to their peers with healthy weight (Goldschmidt, Aspen, Sinton, Tanofsky-Kraff, & Wilfley, 2008). With rates of overweight/obesity as high as 35.1%, this has the potential to impact a large number of youth (Yaemsiri, Slining, & Agarwal, 2011). However, misperception of weight status is common in adolescents (Deschamps, Salanave, Chan-Chee, Vernay, & Castetbon, 2015; Edwards, Pettingell, & Borowsky, 2010; Patte, Laxer, Qian, & Leatherdale, 2016) as they are more likely to underestimate their weight, particularly if they have overweight (Edwards et al., 2010; Patte et al., 2016). Studies have found that individuals who perceive themselves as overweight or obese, independent of objective weight status, are more likely to have greater intentions to lose weight through dieting and/or exercise than those determined to have overweight or obesity based on BMI percentile (Duncan et al., 2011; Fan, Jin, & Khubchandani, 2014; Patte et al., 2016; Yaemsiri et al., 2011). This suggests that weight perception is a more accurate predictor of weight control intentions. Studies also show that individuals who perceive themselves as overweight or obese are more likely to engage in disordered eating behaviors than those that perceive themselves to be normal/healthy weight (Alkazemi, Zafar, Ebrahim, & Kubow, 2018; Cheung, Ip, Lam, & Bibby, 2007). However, it is unclear whether teens with overweight or obesity differ in their use of searching for information on health behavior change compared to healthy weight teens.

Existing research on the use of the internet for nutritional information is often conducted using adult samples and rarely adolescent or youth samples. To our knowledge, there is a dearth of literature examining the nutritional information sought by young adolescent internet users. Young adolescence (10–15 years old) is a key developmental period characterized by increased autonomy and exposure to social and societal pressures (Lane, Brundage, & Kreinin, 2017). Young adolescents are also likely to have greater access to the internet than younger children (Lenhart et al., 2010). Additionally, there is research that suggests that the average age of onset of eating disorders is 16–18 years old (Marzilli, Cerniglia, & Cimino, 2018; Patton, Selzer, Coffey, Carlin, & Wolfe, 1999; Volpe et al., 2016). Since dieting is often a precursor to the development of eating disorders (Patton et al., 1999), it is possible that young adolescents with clinical or subclinical eating disorder symptoms are using internet sources to obtain information for diet modification. Given this, it is important to study the frequency and patterns of use of the internet for nutritional information in a young adolescent sample so that appropriate interventions can be implemented.

The present study aimed to (1) assess the frequency of use of different internet sources to obtain nutritional information in a diverse sample of young adolescents who presented to their primary care physician for an acute or well-child visit; (2) assess whether the frequency of use of these different internet sources to obtain nutritional information differed between normal/healthy weight young adolescents and young adolescents with overweight/obesity based on both perceived and objective weight status; (3) evaluate the relationships between the use of different internet sources for nutritional information and disordered eating behaviors, and (4) determine if greater use of any of the internet sources of nutritional information mediated the relationship between weight perception and disordered eating, as well as objective weight status and disordered eating.

We hypothesized that there would be significantly greater use of each of the internet sources among young adolescents that perceived themselves as overweight/obese compared to those that perceived themselves as normal/healthy weight. We did not expect there to be significant differences in use of each of the internet sources between young adolescents with normal/healthy weight and young adolescents with overweight/obesity as determined by BMI percentile. We hypothesized that use of each of the internet sources for nutritional information would relate to disordered eating behaviors in young adolescents such that more frequent use would be associated with greater disordered eating behaviors. Lastly, we expected that more frequent use of each of the internet sources for nutritional information would mediate the positive relationship between perceived weight status and disordered eating behaviors, but not objective weight status and disordered eating behaviors.