International Journal of
Environmental Research
and Public Health
Article
The Direct and Indirect Eﬀects of Online Social
Support, Neuroticism, and Web Content
Internalization on the Drive for Thinness among
Women Visiting Health-Oriented Websites
Nikol Kvardova *, Hana Machackova and David Smahel
Faculty of Social Studies, Masaryk University, 60200 Brno, Czech Republic; hmachack@fss.muni.cz (H.M.);
smahel@fss.muni.cz (D.S.)
* Correspondence: nikol.kvardova@fss.muni.cz
Received: 31 December 2019; Accepted: 1 April 2020; Published: 2 April 2020
Abstract: One of the debates about media usage is the potential harmful eﬀect that it has on body
image and related eating disturbances because of its representations of the “ideal body”. This study
focuses on the drive for thinness among the visitors of various health-oriented websites and online
platforms because neither has yet been suﬃciently studied in this context. Speciﬁcally, this study aims
to bring more insight to the risk factors which can increase the drive for thinness in the users of these
websites. We tested the presumption that web content internalization is a key factor in this process,
and we considered the eﬀects of selected individual factors, speciﬁcally the perceived online social
support and neuroticism. We utilized survey data from 445 Czech women (aged 18–29, M = 23.5,
SD = 3.1) who visited nutrition, weight loss, and exercise websites. The results showed a positive
indirect link between both perceived online social support and neuroticism to the drive for thinness
via web content internalization. The results are discussed with regard to the dual role of online
support as both risk and protective factor. Moreover, we consider the practical implications for eating
behavior and weight-related problems with regard to prevention and intervention.
Keywords: drive for thinness; health-oriented websites; online social support; neuroticism; web
content internalization
1. Introduction
Considering Western culture and its orientation toward appearance, young girls and women are
susceptible to the desire to be thin so they would achieve an ideal body shape [1,2]. According to
the Tripartite Inﬂuence Model [3], women internalize idealized thin body shapes from the media,
which includes traditional mass media and the internet, including health-oriented websites. Exposure
to thin-ideal content can have a negative impact on women because it is associated with their drive for
thinness and eating disturbances [4,5].
In this study, we focus on the drive for thinness, which is motivation for a thin or thinner body
and the desire to lose weight [1,6]. It is considered a risk factor for well-being because it is associated
with decreased psychological health and the later development of anorexia and bulimia nervosa [7,8].
Because of its potential harm, it is crucial to understand the factors that are associated with the drive
for thinness. Although previous studies investigated the role of the media in relation to the drive
for thinness [1,5,9], there is a lack of evidence for health-oriented websites and the role they play in
promoting weight loss. We intend to contribute to this area by focusing on these types of websites
within the theoretical framework of the Tripartite Inﬂuence Model [3]. Moreover, our aim is to enrich
this model, which posits socio-cultural inﬂuences on eating disturbances, by including the role of the
Int. J. Environ. Res. Public Health 2020, 17, 2416; doi:10.3390/ijerph17072416 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 2416 2 of 14
individual factors associated with the drive for thinness. Speciﬁcally, we examine the role of these
websites for the perceived online social support, neuroticism, and internalization, and their direct and
indirect eﬀects on the drive for thinness.
As a result, our aim is to extend the knowledge about the role of health-related websites in the
development of eating disorders by showing how and for whom these online spaces pose a risk.
Based on our conclusions, we propose recommendations for prevention and intervention eﬀorts.
1.1. Drive for Thinness and Health-Oriented Websites
The drive for thinness is a motivational orientation toward having a thin or thinner body and
a desire to lose weight [1,6]. It emerges as a motivated behavior in order to reduce body-related
discontent [10], which is manifested by eating restraint and a preoccupation with body shape and
weight [11]. It is considered a risk factor to women’s health because it is associated with decreased
psychological well-being, like body dissatisfaction [10], body-related anxiety [12], lower self-esteem [8],
or perceived stress [13]. Moreover, the drive for thinness is one of the diagnostic criteria for anorexia
and bulimia nervosa, and it is associated with the later development of both [7,8,11]. The ideal of
thinness [1], the drive for thinness, and related eating disorders are more prevalent in women than in
men [14]. Therefore, we focused the study on women.
Considering the potential detrimental eﬀects, it is important to understand the factors which
exacerbate the drive for thinness. According to the Tripartite Inﬂuence Model [3], there are three main
inﬂuences on disordered eating: parents, peers, and the media. The role of the media has been highly
debated in relation to disordered eating. In the past two decades, substantial attention has been given
to the role of new technologies, such as social networking sites, eating- and exercise-related websites,
personal blogs with pro-eating disorder content, and various health-related discussion forums [15].
We focus on websites related to weight loss, nutrition, and exercise. These websites act as important
sources for general online information related to nutrition, ﬁtness, weight loss, and a healthy lifestyle.
There are plenty of websites that address these topics, including personal blogs, informational websites
for particular health-related themes, discussion forums, and social-networking groups [16,17]. Websites
can be focused on weight loss, body shaping, healthy lifestyle, eating, dieting, nutrition plans for
speciﬁc illnesses, recipes, and exercising [15,18,19]. Visitors may go through content, read articles,
make and read comments, and obtain advice and inspiration. Moreover, websites can serve as a social
environment where people interact with messages, comments, and evaluations, and they are places
where people can receive support from other visitors [20–22].
However, these websites can have a negative impact on women because they display content
that is associated with the drive for thinness, body dissatisfaction, and eating disturbances [4,5,23,24].
Speciﬁcally, some of these websites display pro-ED (pro-eating disorder) content that suggests that
maintaining an eating disorder is a positive lifestyle choice [25]. They also contain positive comments
about being thin, guilt-inducing messages related to food, stigmatization about weight, and expressions
of negativity about being fat or overweight. They include content related to dieting and eating restraint,
and the promotion of a thin-ideal appearance [18,26]. This appearance-oriented content can have a
negative eﬀect on women through the maintenance of weight- and appearance-related concerns [27].
The current study focuses on young female visitors of health-oriented websites in the Czech
Republic. According to the data from Eurostat [28], 54% of Czech women aged 16 to 29 searched for
online health-related information in 2016, which is the year when the data for our study was collected.
The European average during that time was 60% of young women. Concerning the general usage of
the internet, 95% of Czech women aged 16 to 29 stated that they used the internet in the preceding three
months in 2016, whereas the European average was 96% [29]. This means that the usage of the internet
and the online health seeking behavior among Czech women is similar as in other European countries.
Int. J. Environ. Res. Public Health 2020, 17, 2416 3 of 14
1.2. Internalization
The negative eﬀect of the exposure to the appearance-related online content can be explained
with the Tripartite Inﬂuence Model, which suggests that the link between exposure to media ideals
and eating disorders is not direct. It proposes that internalization of the appearance ideals serves as a
mediating factor interfering association between media eﬀect and disordered eating [30]. Media impact
on disordered eating via internalization, as proposed by Tripartite Inﬂuence Model, was examined
and supported by previous studies [31–35]. In the context of developing and maintaining eating
disturbances, internalization is the process of adopting socially and culturally deﬁned norms about
body shape, which are commonly maintained as body ideals in everyday social interactions and in the
media. By internalizing these ideals, one’s conception of self could be aﬀected because the ideals can
come to represent personal standards against which one could appraise self and others [34]. Since the
idealized appearance depicted by the media does not always correspond with one’s real body shape,
inconsistencies can emerge between the internalized norm and the actual body. Internalized ideals and
perceived discrepancies can lead to consideration about how to obtain this ideal body [1]. This in turn
results in disordered eating.
Several studies investigated speciﬁcally drive for thinness and how it is related to internalized
appearance ideals in adolescent girls and young adult women. Internalization is a signiﬁcant factor
associated with the drive for thinness in both categories [1,8,15,35,36]. Moreover, the mediational
role of internalization in the association between media exposure and the drive for thinness was
supported [15,35]. However, less attention has been given to the individual factors which may be
salient in this process and help explain who is susceptible to internalize media content. Therefore,
in this study, we focus on two factors: online social support and neuroticism.
1.3. Online Social Support
Research has shown that seeking support from others is a frequent motivation for using
health-oriented websites and participating in health-related online groups [37–39]. The online space
oﬀers various ways to get in touch with others, so there are also diverse ways to seek help and receive
support. Social support, which in this context is mostly provided as emotional support, is expressed
through emotions, empathy, and as informational support, like sharing knowledge regarding eating or
ﬁtness activities [21,40].
Online social support has been investigated as an important factor among people who struggle
with eating disorders. For instance, women who engaged in an internet weight loss community
mentioned encouragement, motivation, information, and shared experiences as signiﬁcant resources.
They appreciated the accessibility, the anonymity, and the non-judgmental interactions as unique
characteristics of internet-mediated support [21]. Moreover, examinations of ED discussion forums
and ED-oriented support groups have revealed that these online sites provide relevant information,
emotional support, personal disclosure, help, friendship, peer support, and a safe space to ventilate
feelings [20,22,39,41].
Though receiving social support is, in many occasions, a very beneﬁcial process, we also
examine its potential for the reinforcement of the drive for thinness via increased internalization.
This process can be described with two theories: Social Identity Theory, which refers to an individual’s
knowledge of belonging and the perceived emotional and value signiﬁcance of group membership [42];
and the Self-Categorization Theory [43,44], which depicts how membership in social groups aﬀects an
individual’s behavior. Social identity refers to an individual’s knowledge of belonging and perceived
emotional and value signiﬁcance of group membership [42]. Social identity can act as the basis
for both giving and receiving social support. Perceived social support can additionally promote
the sense of shared identity and the subjective importance of one’s group membership [19,42,45,46].
Subsequently, social identity and group membership are associated with the internalization of group
norms. The norms and attitudes shared within the group are internalized as personal standards
and the individuals act accordingly [47]. On websites related to weight loss, nutrition, and exercise,
Int. J. Environ. Res. Public Health 2020, 17, 2416 4 of 14
users share body-appearance standards, which are demonstrated by the website content, and have
discussions about ideal appearance and ﬁgure [18]. With these shared interests, the goals, the mutual
interaction, and the social support that are exchanged among visitors, the websites have a social
character. Thus, consistent with the Social Identity Theory approach, the perceived social support
from the health-oriented websites can promote a sense of shared social identity and the perception of
salience within the website group membership. Consequently, norms and standards regarding body
appearance can be internalized even more.
1.4. Neuroticism
Neuroticism is deﬁned in terms of the inclination to emotional reactivity, instability, perceived
anxiety, and high vulnerability when coping with stress [33,48,49]. Individuals who are high in
neuroticism are excitable, easily upset, and prone to experiences that are unpleasant [50]. They are
also more sensitive to criticism; they experience higher levels of rejection; and they have lower
self-esteem [51]. In prior research, neuroticism has been connected to the increased drive for thinness
in women [52,53], to heightened food and body preoccupation [54], to body dissatisfaction [55],
to the self-regulation of eating attitudes (e.g., food temptation) [56], and even to eating disorder
diagnosis [48,57] and binge eating [58,59]. According to Fischer, Schreyer, Coughlin, Redgrave,
and Guarda [52], the facets of neuroticism, including irritability and diﬃculty with emotional
regulation, are risk factors for developing an ED. Moreover, disordered eating is associated with
neuroticism because it can serve as a coping mechanism with which neurotic individuals deal with
negative feelings [58,60].
In this study, we examine neuroticism as a risk factor for increased internalization, which can lead
to a stronger drive for thinness. The link was proposed by Scoﬃer-Mériaux et al. [56], who hypothesized
internalization as a mediator between neuroticism and unhealthy dieting behavior. This model was
subsequently tested by Martin and Racine [49], who examined the mediating roles of thin and
athletic-ideal internalization in association between neuroticism, body dissatisfaction, and compulsive
exercise. Using the sample of 531 college students (58% women) aged 18–44, they found that thin-ideal
internalization mediated the link between neuroticism and body dissatisfaction, and the internalization
of athletic ideals mediated the eﬀect of neuroticism on compulsive exercise. Moreover, several prior
studies have found that neuroticism is associated with higher internalization [49,50,56,61]. To explain
this link, Roberts and Good [50] suggest that women with increased neuroticism compare themselves
to attractive people, and this comparison is more likely to result in negativity due to their emotional
liability. This negative eﬀect, which arises from the incongruity between the internalized body ideal
and the actual body shape, can result in an increased drive for thinness, as has been proposed by
previous studies [52,53]. Therefore, we hypothesize that internalization may be a mechanism through
which neuroticism is positively linked to the drive for thinness in women.
1.5. Research Goals
This study focuses on the drive for thinness, which is considered a risk for women’s well-being.
It aims to enhance our understanding of the risk factors that contribute to its development, speciﬁcally
with regard to the inﬂuence of media and the role of individual factors in young women. Previous
studies have shown that the media can have a negative eﬀect on women because exposure to its
content is associated with their desire to have a thin body shape [1,5,9]. However, these studies mainly
investigated traditional media (i.e., TV, magazines) and pro-eating-disorder websites. There is a lack
of research in health-oriented websites, which are currently popular. These websites display content
that is associated with the drive for thinness, body dissatisfaction, and eating disturbances [4,5,23,24].
Therefore, our aim is to ﬁll this gap and bring more insight into the association between visiting
health-related websites and the drive for thinness among women. Furthermore, our study aims to
enrich the Tripartite Inﬂuence Model [3], which is the theoretical framework that explains eating
disturbances with socio-cultural factors, by incorporating neuroticism and perceived social support as
Int. J. Environ. Res. Public Health 2020, 17, 2416 5 of 14
individual factors. Speciﬁcally, we test whether web content internalization mediates the eﬀect of these
factors. We propose that increased neuroticism and perceived online social support positively aﬀects
web content internalization, which in turn aﬀects the drive for thinness. Considering that disordered
eating can be related to age and Body Mass Index [62–64], we also control for both of these factors.
2. Materials and Methods
2.1. Study Sample
This study uses data from a project which focused on the visitors of websites oriented toward
nutrition, weight loss, and exercise. The data were collected through an online survey between May
and October 2016. Participants were recruited with an invitation on 65 Czech websites, web magazines,
social networking sites, blogs, and discussion forums that focused on weight loss, diet, eating habits,
and exercise. The original sample comprised of 1002 respondents (81.6% women, aged 13 to 62,
M = 24.8, SD = 6.9). The project was approved by the Research Ethics Committee of the University.
The current study focuses on a subsample of 445 young adult women, aged 18 to 29 (M = 23.5,
SD = 3.1). Because the ideal of thinness is aimed mainly at women [1] and the drive for thinness and
eating disorders are more prevalent in women [14], we focused on women in our study. Moreover,
young adult women were the major part of the health-oriented website visitors in the project, and we did
not have a suﬃcient amount of data from participants of other ages and genders. The original sample
of women in the age range from 18 to 29 comprised of 632 participants. We excluded respondents based
on their motivation for visiting health-oriented websites and because of missing data. We excluded
women who reported that the reason for their website visits was because of the health issues of
someone else (as indicated by the question Do you visit the sites about nutrition or sports not for yourself,
but mainly because you want to help with the nutrition or sport of another person (partner, child, parent,
etc.)?) (N = 37). In addition, participants with a substantial number of missing values for the key
variables (N = 150) were excluded, and there were no signiﬁcant age diﬀerences between our sample
and excluded respondents (t = 0.37, p = 0.71)).
2.2. Measures
2.2.1. Perceived Online Social Support
Perceived online social support was assessed using three items adapted from Graham,
Papandonatos, Kang, Moreno, and Abrams [65]: I get advice and support here that I would not get
elsewhere; It is encouraging to know that there are other people making similar eﬀorts (with regard to nutrition
or sport); and I feel that other visitors (or authors) of sites are giving me support, with answers that ranged
from 1 = Deﬁnitely does not apply to 4 = Deﬁnitely applies. A higher score indicated higher perceived
support. The internal consistency was acceptable (ř = 0.72, M = 2.8, SD = 0.7).
2.2.2. Neuroticism
We measured neuroticism with three items from the short 15-item Big Five Inventory [66].
The items were I worry a lot; I get nervous easily; and I remain calm in tense situations (reverse scored).
Participants answered on a six-point scale that ranged from 1 = Does not apply to 6 = Deﬁnitely
applies. A higher score indicated higher neuroticism. The internal consistency was acceptable (ř = 0.67,
M = 3.7, SD = 1.1).
2.2.3. Web Content Internalization
Internalization was measured using the question “To what extent do the following statements
apply to you in regards to these sites?” with three items that were adapted from Cusumano and
Thompson [67]: I compare my appearance with people on these sites; I try to look like the people on these sites;
and The content on these sites inspires me in how to look attractive. Participants answered on a six-point
Int. J. Environ. Res. Public Health 2020, 17, 2416 6 of 14
scale that ranged from 1 = Does not apply to 6 = Deﬁnitely applies. A higher score indicated higher
web content internalization. The internal consistency was satisfactory (ř = 0.81, M = 2.4, SD = 0.8).
2.2.4. Drive for Thinness
The Drive for Thinness subscale from Eating Disorder Inventory-3 [68] was used. The scale
consisted of seven items (e.g., I feel extremely guilty after overeating; I am preoccupied with the desire to
be thinner). Participants responded on a six-point scale that ranged from 1 = Never to 6 = Always.
A higher score indicated a higher drive for thinness. The internal consistency was satisfactory (ř = 0.86,
M = 3.4, SD = 1.2). The latent variable was constructed with the parceling approach; speciﬁcally,
we made three parcels, combining low-loading and high-loading items [69]. Parcels were computed as
a mean of the items.
2.2.5. BMI
Participants provided information about their current weight (in kilograms) and height
(in centimeters). BMI was computed as follows: Weight (kg)/Height (m)2.
3. Results
We examined the correlations among the variables (Table 1): perceived online social support,
neuroticism, web content internalization, and the drive for thinness. The results were as expected:
the drive for thinness was positively correlated with online social support (r = 0.11, p = 0.03), web content
internalization (r = 0.51, p < 0.001), and neuroticism (r = 0.23, p < 0.001). Web content internalization
was positively associated with online social support (r = 0.24, p < 0.001) and neuroticism (r = 0.16,
p < 0.001). Additionally, the drive for thinness was positively associated with BMI (r = 0.20, p < 0.001),
but not with age (r = 0.02, p = 0.67).
Table 1. Correlations among variables.
Examined
Variables
Drive for
Thinness
Online
Support
Neuroticism Internalization BMI Age
Drive for thinness
Online support 0.11 *
Neuroticism 0.23 * −0.01
Internalization 0.51 * 0.24 * 0.16 *
BMI 0.20 * 0.07 0.10 * 0.02
Age 0.02 0.002 −0.04 −0.05 0.15 *
Note: * designates p < 0.05.
To test our presumptions, Structural Equation Modeling (SEM) was used with a Robust Maximum
Likelihood (MLR) estimator. We used R software, and lavaan, semTools, and semPlot packages.
We tested a model with indirect eﬀects, predicting drive for thinness. We included neuroticism
and online social support as predictors, the web content internalization as a mediator of the eﬀect
of neuroticism and social support, and age and BMI as controls. The model had an acceptable ﬁt,
CFI = 0.98, TLI = 0.97, RMSEA = 0.04. Results are displayed in Figure 1 and Table 2.
Int. J. Environ. Res. Public Health 2020, 17, 2416 7 of 14
Int. J. Environ. Res. Public Health 2020, 17, x 7 of 14
Figure 1. Path diagram with standardized regression coefficients (β). Note: * designates p < 0.05.
Perceived online social support from health-oriented websites predicted web content
internalization (β = 0.28, p < 0.001). Perceived online social support did not have a strong direct effect
on the drive for thinness, though the effect was weak and marginally significant (β = −0.11, p = 0.06;
CI = −0.61; 0.01). Moreover, we found a significant indirect effect for online social support on the
drive for thinness via web content internalization (β = 0.16, p = 0.001).
Neuroticism predicted web content internalization (β = 0.24, p < 0.001), and it had a direct effect
on the drive for thinness (β = 0.14, p = 0.01). Moreover, we found a significant indirect effect for
neuroticism on the drive for thinness through web content internalization (β = 0.14, p < 0.001).
Therefore, the link between neuroticism and the drive for thinness was partially mediated by the
web content internalization. Regarding controls, BMI positively predicted the drive for thinness (β =
0.17, p = 0.001), but there was no association between age and the drive for thinness (β = 0.02, p =
0.60).
Table 2. Structural Equation Modeling (SEM) predicting the drive for thinness and web content
internalization.
Drive for Thinness b SE p β CI
BMI 0.05 0.01 0.001 0.17 (0.03; 0.07)
Age 0.008 0.02 0.60 0.02 (−0.03; 0.05)
Web content internalization 0.77 0.09 < 0.001 0.58 (0.59; 0.95)
Online social support
Direct effect −0.30 0.16 0.06 −0.11 (−0.61; 0.01)
Indirect effect 0.44 0.13 0.001 0.16 (0.19; 0.69)
Neuroticism
Direct effect 0.14 0.06 0.01 0.14 (0.02; 0.26)
Indirect effect 0.14 0.04 < 0.001 0.14 (0.06; 0.22)
Web content internalization b SE p β CI
Online social support 0.57 0.16 < 0.001 0.28 (0.26; 0.88)
Neuroticism 0.18 0.05 < 0.001 0.24 (0.08; 0.28)
4. Discussion
In our study, we examined the factors associated with the drive for thinness in young adult
women who visited websites oriented toward weight loss, nutrition, and exercise. Specifically, we
investigated the perceived online social support of other website visitors, the neuroticism, and the
web content internalization of the body appearance standards, and their direct and indirect effects
on the drive for thinness. Our objective was to investigate whether the web content internalization
mediates the links among the perceived online social support, the neuroticism, and the drive for
Figure 1. Path diagram with standardized regression coeﬃcients (β). Note: * designates p < 0.05.
Perceived online social support from health-oriented websites predicted web content
internalization (β = 0.28, p < 0.001). Perceived online social support did not have a strong direct eﬀect
on the drive for thinness, though the eﬀect was weak and marginally signiﬁcant (β = −0.11, p = 0.06;
CI = −0.61; 0.01). Moreover, we found a signiﬁcant indirect eﬀect for online social support on the drive
for thinness via web content internalization (β = 0.16, p = 0.001).
Neuroticism predicted web content internalization (β = 0.24, p < 0.001), and it had a direct
eﬀect on the drive for thinness (β = 0.14, p = 0.01). Moreover, we found a signiﬁcant indirect eﬀect
for neuroticism on the drive for thinness through web content internalization (β = 0.14, p < 0.001).
Therefore, the link between neuroticism and the drive for thinness was partially mediated by the web
content internalization. Regarding controls, BMI positively predicted the drive for thinness (β = 0.17,
p = 0.001), but there was no association between age and the drive for thinness (β = 0.02, p = 0.60).
Table 2. Structural Equation Modeling (SEM) predicting the drive for thinness and web content
internalization.
Drive for Thinness b SE p β CI
BMI 0.05 0.01 0.001 0.17 (0.03; 0.07)
Age 0.008 0.02 0.60 0.02 (−0.03; 0.05)
Web content internalization 0.77 0.09 <0.001 0.58 (0.59; 0.95)
Online social support
Direct eﬀect −0.30 0.16 0.06 −0.11 (−0.61; 0.01)
Indirect eﬀect 0.44 0.13 0.001 0.16 (0.19; 0.69)
Neuroticism
Direct eﬀect 0.14 0.06 0.01 0.14 (0.02; 0.26)
Indirect eﬀect 0.14 0.04 <0.001 0.14 (0.06; 0.22)
Web content internalization b SE p β CI
Online social support 0.57 0.16 <0.001 0.28 (0.26; 0.88)
Neuroticism 0.18 0.05 <0.001 0.24 (0.08; 0.28)
4. Discussion
In our study, we examined the factors associated with the drive for thinness in young adult women
who visited websites oriented toward weight loss, nutrition, and exercise. Speciﬁcally, we investigated
the perceived online social support of other website visitors, the neuroticism, and the web content
internalization of the body appearance standards, and their direct and indirect eﬀects on the drive
Int. J. Environ. Res. Public Health 2020, 17, 2416 8 of 14
for thinness. Our objective was to investigate whether the web content internalization mediates the
links among the perceived online social support, the neuroticism, and the drive for thinness. We found
support for our presumption: both online support and neuroticism were positively linked with the
tendency for internalization, which, in turn, increased the drive for thinness.
In our data, we found a substantial connection between internalization and the drive for thinness.
Our ﬁndings are in line with the Tripartite Inﬂuence Model [3,31–33], which suggests that body
image concerns and eating disorders are aﬀected by socio-cultural factors (e.g., media pressure,
parental criticism, peer criticism) and indirectly through the internalization of the medialized body
ideals. Moreover, we enriched the propositions of the Tripartite Inﬂuence Model [3] by including
individual factors. This line of research was recently developed in studies that focused on perfectionism,
self-esteem, depression, and anxiety [30–34,70]. This focus helps to better understand the risk factors,
which strengthen the tendency for internalization.
Speciﬁcally, we found that perceived support increased the drive for thinness via its reinforcement
of internalization. Our ﬁndings correspond to knowledge regarding ED (eating disorders) online
groups, in which perceived support was connected to a higher sense of belonging and the acceptance
of thin-ideal norms [20,22,39,71]. ED online groups and communities act as an important source of
support that can be diﬃcult to obtain elsewhere for individuals who struggle with ED and body image
concerns [39,41]. However, support received from these online groups can be detrimental to women’s
health because it endorses negative attitudes toward their bodies and promotes extremely thin body
shapes as attainable standards. Haas et al. [72] examined the social support on pro-anorexia websites
and discovered that visitors received support for eating restraint and reinforcement for their negative
views of themselves and their bodies. Sowles et al. [73] pointed out that members of the pro-ED online
community disseminate images that depict thin body shapes and promote the thin ideal by labeling
them as their desired goals. Similar ﬁndings emerged from a study by Marcus [40], who found that
members of a pro-anorexic community shared photos of extremely thin bodies to motivate users to
maintain their diets and to outline the beauty standards of the group. In this manner, women are
encouraged to adopt body appearance standards that lead to a desire for a thin body. The ﬁndings
of our study suggest that these processes apply not only to ED online groups, but to health-related
websites as well.
Health-oriented websites, with their opportunities for social interaction (e.g., discussion with
other users about speciﬁc health-related topics, personal messages, inspiration, sharing experiences,
memories, feelings), enable visitors to receive social support. The perceived social support is associated
with the acceptance of group norms due to the higher subjective salience of the social group to which
the individuals belong [40,44,47]. In line with social identity theory [44], the stronger identiﬁcation
with a group would result in the acceptance of group norms and, in the case of websites focusing on
nutrition and ﬁtness—these probably supported the thin and ﬁtness-oriented images of the ideal body.
Thus, though the perceived support is often seen as a positive aspect of online interaction, in these
instances, it may result in negative outcomes. However, when interpreting these results, the limitations
of this study should be taken into consideration. Due to the correlational nature of the data used, it was
not possible to draw causal conclusions. Thus, the association between online social support and the
drive for thinness may work in the opposite direction, meaning that women with a stronger drive
for thinness may more often seek social support for their goals and eﬀorts in the online space and,
speciﬁcally, via health-oriented websites.
Moreover, this ﬁnding should also be compared to the results for the direct eﬀect of support on
the drive for thinness. This eﬀect was rather weak and just marginally signiﬁcant; however, it may
indicate that the role of support is diverse. If we disentangle the indirect eﬀect that positively aﬀects the
drive for thinness from the direct eﬀect, we ﬁnd that support negatively aﬀected the drive for thinness.
To interpret this ﬁnding, we should acknowledge that perceived support helps to increase overall
well-being [74–76], which decreases the tendency for unhealthy and disordered eating habits [77,78].
Thus, perceived online social support can actually function as both a risk and a protective factor. On one
Int. J. Environ. Res. Public Health 2020, 17, 2416 9 of 14
hand, it may contribute to the development of the drive for thinness via increased internalization.
On the other hand, it may also serve as a buﬀer for this negative eﬀect, probably via the increase
of overall well-being, which was not included in this study. This presumption could be pursued in
future examinations.
Thus, we still need to consider other factors which underlie the internalization of the web content.
Our study focused on neuroticism, which showed to be positively linked to the drive for thinness and
also had an indirect eﬀect via internalization. Therefore, the eﬀect of neuroticism on women’s drive for
thinness was partially mediated by the internalization of the body appearance standards displayed
on health-oriented websites. In line with prior studies [49,50,52,53,56,61], our ﬁndings showed that
people with heightened neuroticism are more prone to accepting the norms, and, probably because of
the increased tendency for social comparison, tend more to strive to be thin.
However, besides the mediated eﬀect, we also found a direct positive link to the drive for thinness.
This suggests that increased internalization is not the only mechanism through which people with
neurotic traits can be more at risk. However, considering that we found support for the tendency for
heightened internalization from the websites, and upon the propositions of the Tripartite Inﬂuence
Model [3], we could expect that the mechanism could be similar in relation to parental and peer norms,
which have not been measured in this study. This poses one of the limitations for our study.
Concerning other limitations, it should be stressed that we used cross-sectional correlational
data based on a sample that was self-selected through health-oriented websites. Thus, though we
examined the proposed model for the mechanisms to increase the drive for thinness, the research design
complicates drawing causal conclusions. Future research should implement a longitudinal research
design to make more reliable causal conclusions and to capture potential reciprocal associations.
Moreover, we were not able to control for the eﬀects of additional variables on the drive for thinness.
These are factors (e.g., body dissatisfaction) [79] that are related to the drive for thinness and disordered
eating, and it would be appropriate to control for their eﬀects to obtain more accurate results.
Furthermore, we do not have information about the speciﬁc content that respondents encountered.
It would be useful to incorporate objective measures and directly observe the eﬀects of participants’
exposure to online content. Finally, although the thin ideal displayed in the media and the related drive
for thinness is more prominent in women [1], future research could focus on men, their internalization
of the body appearance norms, and their motivations for body change.
In the current study, our aim was to propound a model that comprises of the individual factors
that aﬀect women’s drive for thinness. Based on our ﬁndings, we can formulate several implications.
According to the theory and the available data, we propose the following processes: online social
support from the visitors of health-oriented websites and neuroticism aﬀect the drive for thinness,
and these links are mediated by the internalization of body appearance standards. Thus, alongside
previous research in this area [1,8,15,35,36], our study supported the predictive role of internalization in
the drive for thinness among women. Speciﬁcally, our study provided insight into the internalization
of the content of health-oriented websites, which had not been suﬃciently investigated and had not
been taken into account in relation to women’s drive for thinness. Our results imply that it is crucial to
acknowledge health-oriented websites and their potential impact on women, especially in the context
of the internalization of body appearance norms. Health-oriented websites, which are not generally
acknowledged as harmful to women’s body image, can be a signiﬁcant source of body appearance
norms and subsequent body image concerns [18]. As was discovered in the current study, women
internalize body ideals from health-oriented websites and this, in turn, increases their drive for thinness.
This connection should be actively acknowledged by health-care professionals. It is important for
professionals to ask their clients who have ED-related problems about their technology usage and to
provide them with space to talk about it [80]. Thus, in the context of the current study, health-care
professional should discuss with clients who are struggling with EDs their usage of health-oriented
websites, speciﬁcally with a focus on their exposure to the thin- or ﬁtness-ideal content.
Int. J. Environ. Res. Public Health 2020, 17, 2416 10 of 14
We also showed that both online support and neuroticism present risk factors because they can
increase the tendency for internalization and, in turn, increase the drive for thinness. Therefore, it is
important to be aware of the possible negative eﬀect that online social support may have on women
and to address it when preventing or reducing the drive for thinness. However, the ﬁndings of this
study showed that online social support can function both as a risk and a protective factor. Thus,
when discussing the use of health-oriented websites with ED clients, it is important to disentangle the
diﬀerent forms of social support that women receive from the visitors of these platforms. In addition,
neurotic individuals experience higher levels of negative emotions and stress, which makes them more
susceptible [52,53]. Based on our results, we suggest that preventive health programs, intervention,
individual psychotherapy, counseling, and other health policies can be focused on the reduction of the
negative emotions and stress in women. These can also help the reduction of the internalization of the
body appearance standards promoted on health-oriented websites.
5. Conclusions
This study focused on the factors associated with the drive for thinness in young adult women
who visited weight loss, nutrition, and exercise websites. These platforms are currently of high use,
yet they have not been suﬃciently studied in relation to eating disturbances. We examined the direct
and indirect eﬀects of perceived online social support from fellow website visitors, neuroticism,
and the web content internalization of the body appearance standards on the drive for thinness.
Our ﬁndings supported the predictive role of web content internalization on the drive for thinness in
women. Moreover, we showed that the perceived online support from the health-oriented websites and
neuroticism can pose risk factors because they are associated with a higher tendency for internalization
and, in turn, with a stronger drive for thinness. Our results indicate that it is crucial to acknowledge
health-oriented websites and their potential impact on women and their drive for thinness, especially
in the context of the internalization of body appearance standards. We also discuss the role of social
support, and its double role of risk and protection. Our ﬁndings can be used to establish prevention
and intervention eﬀorts to help individuals who struggle with body image and eating disturbances.
Author Contributions: Writing—original draft preparation, N.K.; writing—review and editing, N.K., H.M. and
D.S..; supervision, H.M. and D.S.; project administration, H.M. and D.S.; formal analysis, N.K. All authors have
read and agreed to the published version of the manuscript.
Funding: This research and the APC were funded by Czech Science Foundation, grant number 19-27828X
(project FUTURE).
Conﬂicts of Interest: The authors declare no conﬂict of interest.
References
1. Pritchard, M.; Cramblitt, B. Media Inﬂuence on Drive for Thinness and Drive for Muscularity. Sex Roles 2014,
71, 208–218. [CrossRef]
2. Warren, C.S.; Gleaves, D.H.; Cepeda-Benito, A.; Fernandez, M.D.C.; Rodriguez-Ruiz, S. Ethnicity as a
Protective Factor against Internalization of a Thin Ideal and Body Dissatisfaction. Int. J. Eat. Disord. 2005,
37, 241–249. [CrossRef] [PubMed]
3. Thompson, J.K.; Heinberg, L.J.; Altabe, M.; Tantleﬀ-Dunn, S. Exacting Beauty: Theory, Assessment, and Treatment
of Body Image Disturbance; American Psychological Association: Washington, DC, USA, 1999.
4. Harper, K.; Sperry, S.; Thompson, J.K. Viewership of Pro-Eating Disorder Websites: Association with Body
Image and Eating Disturbances. Int. J. Eat. Disord. 2008, 41, 92–95. [CrossRef] [PubMed]
5. Juarez, L.; Soto, E.; Pritchard, M.E. Drive for Muscularity and Drive for Thinness: The Impact of Pro-Anorexia
Websites. Eat. Disord. 2012, 20, 99–112. [CrossRef]
6. Jones, M.E.; Blodgett Salaﬁa, E.H.; Hill, B.D. The Eﬀect of Parental Warmth on Girls’ Drive for Thinness:
Do Both Parents Matter? J. Child Fam. Stud. 2019, 28, 182–191. [CrossRef]
Int. J. Environ. Res. Public Health 2020, 17, 2416 11 of 14
7. De Pasquale, C.; Pistorio, M.L.; Tornatore, E.; De Berardis, D.; Fornaro, M. The Relationship between Drive
to Thinness, Conscientiousness and Bulimic Traits during Adolescence: A Comparison between Younger
and Older Cases in 608 Healthy Volunteers. Ann. Gen. Psychiatry 2013, 12. [CrossRef]
8. Fernandez, S.; Pritchard, M. Relationships between Self-Esteem, Media Inﬂuence and Drive for Thinness.
Eat. Behav. 2012, 13, 321–325. [CrossRef]
9. Tiggemann, M. The Role of Media Exposure in Adolescent Girls’ Body Dissatisfaction and Drive for Thinness:
Prospective Results. J. Soc. Clin. Psychol. 2006, 25, 523–541. [CrossRef]
10. Sands, R. Reconceptualization of Body Image and Drive for Thinness. Int. J. Eat. Disord. 2000, 28, 397–407.
[CrossRef]
11. Wiederman, M.W.; Pryor, T.L. Body Dissatisfaction, Bulimia, and Depression among Women: The Mediating
Role of Drive for Thinness. Int. J. Eat. Disord. 2000, 27, 90–95. [CrossRef]
12. Brunet, J.; Sabiston, C.M.; Dorsch, K.D.; McCreary, D.R. Exploring a Model Linking Social Physique Anxiety,
Drive for Muscularity, Drive for Thinness and Self-Esteem among Adolescent Boys and Girls. Body Image
2010, 7, 137–142. [CrossRef] [PubMed]
13. Warren, C.S.; Holland, S.; Billings, H.; Parker, A. The Relationships between Fat Talk, Body Dissatisfaction,
and Drive for Thinness: Perceived Stress as a Moderator. Body Image 2012, 9, 358–364. [CrossRef] [PubMed]
14. Galmiche, M.; Déchelotte, P.; Lambert, G.; Tavolacci, M.P. Prevalence of Eating Disorders over the 2000–2018
Period: A Systematic Literature Review. Am. J. Clin. Nutr. 2019, 109, 1402–1413. [CrossRef] [PubMed]
15. Tiggemann, M.; Miller, J. The Internet and Adolescent Girls’ Weight Satisfaction and Drive for Thinness.
Sex Roles 2010, 63, 79–90. [CrossRef]
16. Bissonnette-Maheux, V.; Provencher, V.; Lapointe, A.; Dugrenier, M.; Dumas, A.A.; Pluye, P.; Straus, S.;
Gagnon, M.P.; Desroches, S. Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs:
A Qualitative Study. J. Med. Internet Res. 2015, 17, e87. [CrossRef]
17. Ransom, D.C.; La Guardia, J.G.; Woody, E.Z.; Boyd, J.L. Interpersonal Interactions on Online Forums
Addressing Eating Concerns. Int. J. Eat. Disord. 2010, 43, 161–170. [CrossRef]
18. Boepple, L.; Thompson, J.K. A Content Analysis of Healthy Living Blogs: Evidence of Content Thematically
Consistent with Dysfunctional Eating Attitudes and Behaviors. Int. J. Eat. Disord. 2014, 47, 362–367.
[CrossRef]
19. Smahel, D.; Machackova, H.; Smahelova, M.; Cevelicek, M.; Almenara, C.A.; Holubcikova, J. Digital Technology,
Eating Behaviors, and Eating Disorders; Springer: Cham, Switzerland, 2018.
20. Flynn, M.A.; Stana, A. Social Support in a Men’s Online Eating Disorder Forum. Int. J. Mens. Health 2012,
11, 150–169. [CrossRef]
21. Hwang, K.O.; Ottenbacher, A.J.; Green, A.P.; Cannon-Diehl, M.R.; Richardson, O.; Bernstam, E.V.; Thomas, E.J.
Social Support in an Internet Weight Loss Community. Int. J. Med. Inform. 2010, 79, 5–13. [CrossRef]
22. McCormack, A. Individuals with Eating Disorders and the Use of Online Support Groups as a Form of Social
Support. CIN Comput. Inform. Nurs. 2010, 28, 12–19. [CrossRef]
23. Custers, K.; Van den Bulck, J. Viewership of Pro-Anorexia Websites in Seventh, Ninth and Eleventh Graders.
Eur. Eat. Disord. Rev. 2009, 17, 214–219. [CrossRef] [PubMed]
24. Rouleau, C.R.; Von Ranson, K.M. Potential Risks of Pro-Eating Disorder Websites. Clin. Psychol. Rev. 2011,
31, 525–531. [CrossRef] [PubMed]
25. Turja, T.; Oksanen, A.; Kaakinen, M.; Sirola, A.; Kaltiala-Heino, R.; Räsänen, P. Proeating Disorder Websites
and Subjective Well-Being: A Four-Country Study on Young People. Int. J. Eat. Disord. 2017, 50, 50–57.
[CrossRef] [PubMed]
26. Ging, D.; Garvey, S. ‘Written in These Scars Are the Stories I Can’t Explain’: A Content Analysis of pro-Ana
and Thinspiration Image Sharing on Instagram. New Media Soc. 2018, 20, 1181–1200. [CrossRef]
27. Carrotte, E.R.; Vella, A.M.; Lim, M.S. Predictors of “Liking” Three Types of Health and Fitness-Related
Content on Social Media: A Cross-Sectional Study. J. Med. Internet Res. 2015, 17, e205. [CrossRef] [PubMed]
28. Eurostat. Women Aged 16–29 Using the Internet For Seeking Health-Related Information. Available online:
https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=isoc_ci_ac_i&lang=en (accessed on 28 March 2020).
29. Eurostat. Women Aged 16–29 Using the Internet in Last Three Months. Available online: https://appsso.
eurostat.ec.europa.eu/nui/show.do?dataset=isoc_ci_ifp_iu&lang=en (accessed on 28 March 2020).
Int. J. Environ. Res. Public Health 2020, 17, 2416 12 of 14
30. Van Den Berg, P.; Thompson, J.K.; Obremski-Brandon, K.; Coovert, M. The Tripartite Inﬂuence Model of
Body Image and Eating Disturbance A Covariance Structure Modeling Investigation Testing the Mediational
Role of Appearance Comparison. J. Psychosom. Res. 2002, 53, 1007–1020. [CrossRef]
31. Huxley, C.J.; Halliwell, E.; Clarke, V. An Examination of the Tripartite Inﬂuence Model of Body Image:
Does Women’s Sexual Identity Make a Diﬀerence? Psychol. Women Q. 2015, 39, 337–348. [CrossRef]
32. Keery, H.; van den Berg, P.; Thompson, J.K. An Evaluation of the Tripartite Inﬂuence Model of Body
Dissatisfaction and Eating Disturbance with Adolescent Girls. Body Image 2004, 1, 237–251. [CrossRef]
33. Pokrajac-bulian, A. Thin-Ideal Internalization and Comparison Process as Mediators of Social Inﬂuence and
Psychological Functioning in the Development of Disturbed Eating Habits in Croatian College Females.
Psychol. Top. 2008, 17, 221–245.
34. Jones, D.C.; Vigfusdottir, T.H.; Lee, Y. Body Image and the Appearance Culture among Adolescent Girls
and Boys: An Examination of Friend Conversations, Peer Criticism, Appearance Magazines, and the
Internalization of Appearance Ideals. J. Adolesc. Res. 2004, 19, 323–339. [CrossRef]
35. Gilbert, S.C.; Crump, S.; Madhere, S.; Schutz, W. Internalization of the Thin Ideal as a Predictor of Body
Dissatisfaction and Disordered Eating in African, African-American, and Afro-Caribbean Female College
Students. J. Coll. Stud. Psychother. 2009, 23, 196–211. [CrossRef]
36. Low, K.G.; Charanasomboon, S.; Brown, C.; Hiltunen, G.; Long, K.; Reinhalter, K.; Jones, H. Internalization
of the Thin Ideal, Weight and Body Image Concerns. Soc. Behav. Pers. 2003, 31, 81–90. [CrossRef]
37. Peebles, R.; Wilson, J.L.; Litt, I.F.; Hardy, K.K.; Lock, J.D.; Mann, J.R.; Borzekowski, D.L.G. Disordered Eating
in a Digital Age: Eating Behaviors, Health, and Quality of Life in Users of Websites with pro-Eating Disorder
Content. J. Med. Internet Res. 2012, 14. [CrossRef] [PubMed]
38. Reijo, S. Dietary Blogs as Sites of Informational and Emotional Support. Inf. Res. 2010, 15, 2.
39. Tong, S.T.; Heinemann-LaFave, D.; Jeon, J.; Kolodziej-Smith, R.; Warshay, N. The Use of Pro-Ana Blogs for
Online Social Support. Eat. Disord. 2013, 21, 408–422. [CrossRef]
40. Marcus, S.R. Thinspiration vs. Thicksperation: Comparing pro-Anorexic and Fat Acceptance Image Posts on
a Photo-Sharing Site. Cyberpsychology 2016, 10. [CrossRef]
41. Kendal, S.; Kirk, S.; Elvey, R.; Catchpole, R.; Pryjmachuk, S. How a Moderated Online Discussion Forum
Facilitates Support for Young People with Eating Disorders. Health Expect. 2017, 20, 98–111. [CrossRef]
42. Chiu, C.M.; Huang, H.Y.; Cheng, H.L.; Sun, P.C. Understanding Online Community Citizenship Behaviors
through Social Support and Social Identity. Int. J. Inf. Manag. 2015, 35, 504–519. [CrossRef]
43. Tajfel, H.; Turner, J.C. An integrative theory of intergroup conﬂict. In The Social Psychology of Intergroup
Relation; Brooks-Cole: Monrerey, CA, USA, 1979.
44. Tajfel, H. Social Identity and Intergroup Relations; Cambridge University Press: Cambridge, MA, USA, 2010.
45. Deaux, K. Reconstructing Social Identity. Soc. Personal. Soc. Psychol. 1993, 19, 4–12. [CrossRef]
46. Haslam, S.A.; O’Brien, A.; Jetten, J.; Vormedal, K.; Penna, S. Taking the strain: Social identity, social support,
and the experience of stress. Br. J. Soc. Psychol. 2005, 44, 355–370. [CrossRef]
47. Stets, J.E.; Burke, P.J. Identity Theory and Social Identity Theory. Soc. Psychol. Q. 2000, 63, 224–237. [CrossRef]
48. Gual, P.; Pérez-Gaspar, M.; Martinez-Gonzalez, M.A.; Lahortiga, F.; de Irala-Estévez, J.; Cervera-Enguix, S.
Self-Esteem, Personality, and Eating Disorders: Baseline Assessment of a Prospective Population-Based
Cohort. Int. J. Eat. Disord. 2002, 31, 261–273. [CrossRef] [PubMed]
49. Martin, S.J.; Racine, S.E. Personality Traits and Appearance-Ideal Internalization: Diﬀerential Associations
with Body Dissatisfaction and Compulsive Exercise. Eat. Behav. 2017, 27, 39–44. [CrossRef] [PubMed]
50. Roberts, A.; Good, E. Media Images and Female Body Dissatisfaction: The Moderating Eﬀects of the
Five-Factor Traits. Eat. Behav. 2010, 11, 211–216. [CrossRef]
51. Rozgonjuk, D.; Ryan, T.; Kuljus, J.K.; Täht, K.; Scott, G.G. Social Comparison Orientation Mediates the
Relationship between Neuroticism and Passive Facebook Use. Cyberpsychology 2019, 13. [CrossRef]
52. Fischer, L.K.; Schreyer, C.C.; Coughlin, J.W.; Redgrave, G.W.; Guarda, A.S. Neuroticism and Clinical Course
of Weight Restoration in a Meal-Based, Rapid-Weight Gain, Inpatient-Partial Hospitalization Program for
Eating Disorders. Eat. Disord. 2017, 25, 52–64. [CrossRef]
53. Kjelsås, E.; Augestad, L.B. Gender, Eating Behavior, and Personality Characteristics in Physically Active
Students. Scand. J. Med. Sci. Sports 2004, 14, 258–268. [CrossRef]
Int. J. Environ. Res. Public Health 2020, 17, 2416 13 of 14
54. Ellickson-Larew, S.; Naragon-Gainey, K.; Watson, D. Pathological Eating Behaviors, BMI, and Facet-Level
Traits: The Roles of Conscientiousness, Neuroticism, and Impulsivity. Eat. Behav. 2013, 14, 428–431.
[CrossRef]
55. MacNeill, L.P.; Best, L.A.; Davis, L.L. The Role of Personality in Body Image Dissatisfaction and Disordered
Eating: Discrepancies between Men and Women. J. Eat. Disord. 2017, 5, 44. [CrossRef]
56. Scoﬃer-Mériaux, S.; Falzon, C.; Lewton-Brain, P.; Filaire, E.; d’arripe-Longueville, F. Big Five Personality
Traits and Eating Attitudes in Intensively Training Dancers: The Mediating Role of Internalized Thinness
Norms. J. Sports Sci. Med. 2015, 14, 627–633.
57. Cervera, S.; Lahortiga, F.; Martinez-Gonzalez, M.A.; Gual, P.; de Irala-Estevez, J.; Alonso, Y. Neuroticism and
Low Self-Esteem as Risk Factors for Incident Eating Disorders in a Prospective Cohort Study. Int. J. Eat.
Disord. 2003, 33, 271–280. [CrossRef] [PubMed]
58. Izydorczyk, B. Neuroticism and Compulsive Overeating (A Comparative Analysis of the Level of Neuroticism
and Anxiety in a Group of Females Suﬀering from Psychogenic Binge Eating, and in Individuals Exhibiting
No Mental or Eating Disorders). Arch. Psychiatry Psychother. 2012, 14, 5–13.
59. Koren, R.; Munn-Chernoﬀ, M.A.; Duncan, A.E.; Bucholz, K.K.; Madden, P.A.F.; Heath, A.C.; Agrawal, A.
Is the Relationship between Binge Eating Episodes and Personality Attributable to Genetic Factors? Twin Res.
Hum. Genet. 2014, 17, 65–71. [CrossRef] [PubMed]
60. Henderson, Z.B.; Fox, J.R.E.; Trayner, P.; Wittkowski, A. Emotional Development in Eating Disorders:
A Qualitative Metasynthesis. Clin. Psychol. Psychother. 2019, 26, 440–457. [CrossRef] [PubMed]
61. Heinberg, L.J.; Coughlin, J.W.; Pinto, A.M.; Haug, N.; Brode, C.; Guarda, A.S. Validation and Predictive
Utility of the Sociocultural Attitudes toward Appearance Questionnaire for Eating Disorders (SATAQ-ED):
Internalization of Sociocultural Ideals Predicts Weight Gain. Body Image 2008, 5, 279–290. [CrossRef] [PubMed]
62. Chaudhari, B.; Tewari, A.; Vanka, J.; Kumar, S.; Saldanha, D. The Relationship of Eating Disorders Risk with
Body Mass Index, Body Image and Self-Esteem among Medical Students. Ann. Med Health Sci. Res. 2017,
7, 144–149.
63. Dada, G.; Feixas, G.; Compañ, V.; Montesano, A. Self-Construction, Cognitive Conﬂicts, and Disordered
Eating Attitudes in Young Women. J. Constr. Psychol. 2012, 25, 70–89. [CrossRef]
64. Rojo-Moreno, L.; Rubio, T.; Plumed, J.; Barberá, M.; Serrano, M.; Gimeno, N.; Conesa, L.; Ruiz, E.;
Rojo-Boﬁll, L.; Beato, L.; et al. Teasing and Disordered Eating Behaviors in Spanish Adolescents. Eat. Disord.
2013, 21, 53–69. [CrossRef]
65. Graham, A.L.; Papandonatos, G.D.; Kang, H.; Moreno, J.L.; Abrams, D.B. Development and validation of the
online social support for smokers scale. J. Med Internet Res. 2011, 13, e69. [CrossRef]
66. Lang, F.R.; John, D.; Lüdtke, O.; Schupp, J.; Wagner, G.G. Short assessment of the Big Five: Robust across
survey methods except telephone interviewing. Behav. Res. Methods 2011, 43, 548–567. [CrossRef]
67. Cusumano, D.L.; Thompson, J.K. Media inﬂuence and body image in 8–11-year-old boys and girls:
A preliminary report on the multidimensional media inﬂuence scale. Int. J. Eat. Disord. 2001, 29, 37–44.
[CrossRef]
68. Garner, D.M. Eating Disorder Inventory-3. Professional Manual; Psychological Assessment Resources: Lutz,
FL, USA, 2004.
69. Little, T.D.; Cunningham, W.A.; Shahar, G.; Widaman, K.F. To Parcel or Not to Parcel: Exploring the Question,
Weighing the Merits. Struct. Equ. Model. 2002, 9, 151–173. [CrossRef]
70. Menzel, J.E.; Sperry, S.L.; Small, B.; Thompson, J.K.; Sarwer, D.B.; Cash, T.F. Internalization of Appearance
Ideals and Cosmetic Surgery Attitudes: A Test of the Tripartite Inﬂuence Model of Body Image. Sex Roles
2011, 65, 469–477. [CrossRef]
71. McKinley, C.J. Investigating the inﬂuence of threat appraisals and social support on healthy eating behavior
and drive for thinness. Health Commun. 2009, 24, 735–745. [CrossRef] [PubMed]
72. Haas, S.M.; Irr, M.E.; Jennings, N.A.; Wagner, L.M. Communicating Thin: A Grounded Model of Online
Negative Enabling Support Groups in the pro-Anorexia Movement. New Media Soc. 2011, 13, 40–57.
[CrossRef]
73. Sowles, S.J.; McLeary, M.; Optican, A.; Cahn, E.; Krauss, M.J.; Fitzsimmons-Craft, E.E.; Wilﬂey, D.E.;
Cavazos-Rehg, P.A. A Content Analysis of an Online Pro-Eating Disorder Community on Reddit. Body Image
2018, 24, 137–144. [CrossRef]
Int. J. Environ. Res. Public Health 2020, 17, 2416 14 of 14
74. Espeleta, H.C.; Beasley, L.; Bohora, S.; Ridings, L.E.; Silovsky, J.F. Depression in Latina mothers: Examining
the roles of acculturation, enculturation, social support, and family resources. Cult. Divers. Ethn. Minority
Psychol. 2019, 25, 527–538. [CrossRef]
75. Grieve, R.; Indian, M.; Witteveen, K.; Anne Tolan, G.; Marrington, J. Face-to-face or Facebook: Can social
connectedness be derived online? Comput. Hum. Behav. 2013, 29, 604–609. [CrossRef]
76. Ibrahim, N.; Che Din, N.; Ahmad, M.; Amit, N.; Ghazali, S.E.; Wahab, S.; Abdul Kadir, N.; Halim, F.W.;
Halim, M.R.T.A. The role of social support and spiritual wellbeing in predicting suicidal ideation among
marginalized adolescents in Malaysia. BMC Public Health 2019, 19, 553. [CrossRef]
77. Fitzsimmons, E.E.; Bardone-Cone, A.M. Coping and social support as potential moderators of the relation
between anxiety and eating disorder symptomatology. Eat. Behav. 2011, 12, 21–28. [CrossRef]
78. Wonderlich-Tierney, A.L.; Vander Wal, J.S. The eﬀects of social support and coping on the relationship
between social anxiety and eating disorders. Eat. Behav. 2010, 11, 85–91. [CrossRef] [PubMed]
79. Keski-Rahkonen, A.; Bulik, C.M.; Neale, B.M.; Rose, R.J.; Rissanen, A.; Kaprio, J. Body Dissatisfaction and
Drive for Thinness in Young Adult Twins. Int. J. Eat. Disord. 2005, 37, 188–199. [CrossRef] [PubMed]
80. Šmahelová, M.; ˇCevelíˇcek, M.; Nehybková, E.; Šmahel, D.; ˇCermák, I. Is It Important to Talk about
Technologies with Eating Disorder Clients? The Health-Care Professional Perspective. Health Commun. 2019,
34, 31–38. [CrossRef] [PubMed]
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