Who is the media responsible for?

The role of the media in the development, course and management of eating disorders


Eating disorders are one of the most common psychosomatic illnesses in Western societies. The media has long been blamed for being one of the triggers of eating disorders. For example, it has been shown in several studies that the media convey an unrealistic ideal of beauty and that this can lead to dissatisfaction with their own bodies, especially in young recipients.

However, two central aspects have hardly been considered so far.

On the one hand, there is a lack of studies in which the patients themselves are the focus and the role of the media in the development, progression and coping phase of an eating disorder is considered. On the other hand, there are hardly any studies on how and to what extent the disease is discussed in the media and how such representations affect the affected group.

Based on previous research in this area, it can be assumed that the perception of how one's own illness is presented in the media has consequences for the self-perception, well-being and actions of the sick person. The present article gives an overview of the complex role of media in the context of an eating disorder and shows above all gaps in communication science research on this topic.


Eating disorders are among the most common psychosomatic illnesses in Western societies. For some time now, the media have been blamed as one of the potential triggers of problematic eating behavior. Several studies have shown that the media convey an unrealistic ideal of beauty and that this can cause dissatisfaction with one's own body, especially among young recipients. However, two central aspects have not yet been thoroughly considered. First, there is a lack of research that focuses on people actually affected by an eating disorder and that considers the role of the media in the development, progression, and coping phase of an eating disorder. Second, there is hardly any research on how and to what extent the disease itself is addressed in the media and how such representations influence the affected group - in communication research, this is referred to as reciprocal effects. Based on previous research in this area, it can be assumed that the perception of how one's own illness is portrayed in the media can have consequences for the self-perception, well-being, and actions of ill persons. This article provides an overview of the complex role of the media in the context of an eating disorder and, above all, highlights gaps in communication research on the topic.


Eating disorders are particularly common mental illnesses in western industrialized countries that particularly (but not exclusively) affect young adults [1]. The most common form is so-called anorexia nervosa, followed by eating-vomiting addiction (bulimia nervosa) and binge-eating disorder (recurring binge eating). Even if there are different figures on the prevalence of the diseases, the comparatively high mortality rate, especially from anorexia (according to a meta-analysis from 1998, the highest of all mental illnesses, cf. [2]) indicates the need to deal socially with the topic to deal with. However, mental illness is still considered a topic that is not popularly discussed in public; Affected people feel stigmatized and fear for their social reputation and the reason for this is often the negative and stereotypical portrayal of such diseases in the media [3, 4]. Amazingly, however, there are few empirical findings on how and to what extent eating disorders or other mental illnesses are presented in the media. So far, the media have been looked at almost exclusively as a possible trigger of eating disorders: The predominantly experimental research investigated how idealized body representations in the media affect the body image of young recipients. Although the evidence is heterogeneous, studies showing negative effects predominate (for an overview see [5]).

The role of the media in the context of mental illnesses in general and eating disorders in particular is significantly more complex. First of all, as a factor in a complex network of genetic, social and family conditions, the media can actually be a contributing factor to disrupted eating behavior. Their role in the developmental phase of the disease is important here. In addition, they play a role in the course and in the coping process - both in a positive and a negative way: Above all, content that conveys unrealistic ideals of beauty can have a negative effect on the coping process - but digital offers, online communities and Education formats also have a positive influence on the course of the disease. Finally, mass media content and, above all, entertainment formats have an influence on the image society makes of the disease itself and people with eating disorders. All 3 areas appear to be central to us in a contribution about the connection between media and eating disorders, so that we would like to go into these points in more detail below.

The role of the media in different phases of an eating disorder

Development phase: media (content) as the cause of disturbed eating behavior

Much of the research in the context of media and eating disorders deals with media as potential triggers or drivers for disrupted eating behavior. The starting point for this is initially correlative observations: studies show that the ideal of beauty presented in the media has become increasingly slimmer in recent decades, although the average body mass index (BMI) of women rose over the same period, so that reality and media reality continued to diverge [6]. At the same time, more and more women stated that they were dissatisfied with their own bodies, and the number of diagnosed eating disorders also rose steadily until the 1990s. This observation led to the assumption that the media could be partly responsible for dissatisfaction and eating disorders. Such an observation alone says nothing about the direction of a possible causal relationship, nor that it even exists.

Correspondingly, the relevant research largely consists of experimental studies and some meta-analyzes based on them (e.g. [7,8,9]). In the investigations, mostly young female students are confronted with idealized body representations (e.g. pictures of advertising models, cf. [10, 11]) using random samples based on availability (convenience samples) and then with their body satisfaction and similar concepts, often including the tendency to disturbed eating behavior, asked. The “theory of social comparison processes” [12, 13] and the “cultivation approach” [14,15,16] serve as the theoretical basis. Social comparisons are made permanently, even unconsciously, in everyday life: we explicitly or implicitly compare ourselves with other people with regard to various characteristics such as intelligence, appearance, wealth, social position, etc. Social comparisons focus on situational effects: When viewing an idealized representation of the body in the media There is an upward comparison (the other person is perceived as more attractive), which, depending on the individual, can lead to frustration or depression about one's own appearance / body image or to emulate the role model. Since these presented ideals of beauty are often impossible or difficult to achieve for the average citizen (if only because of the image processing techniques used), the latter can, in the worst case, lead to pathological behavior [17].

The cultivation approach focuses on longer-term effects [14,15,16]: Originally developed with reference to depictions of violence on television, in the first step it assumes that there is a discrepancy or a distortion between actual reality and media reality. As described in the introduction, this is the case in the area of ​​body representations: the average BMI of a woman portrayed in the media is well below the average BMI of the entire western population and this gap has widened in recent years [6]. Due to the constant confrontation with media reality, recipients begin to take it for actual reality and internalize the ideal of beauty presented in the media accordingly.

The findings on the effect of idealized body representations are overall heterogeneous, with studies that have shown a negative influence of idealized body representations on satisfaction with one's own body now predominate. In particular, some “boundary conditions” have already been identified under which such negative effects occur more intensely, such as low self-esteem, existing dissatisfaction with one's own body and a very lean, internalized body ideal [8]. These findings suggest that the media usually does not act as the sole cause, but rather as an amplifier, mediator, or trigger in the process of a potential disease. As is often the case, there is no simple, one-sided Stimulus responseEffect (media cause eating disorders), but rather a complex interaction: People with certain predispositions and possibly even a tendency to problematic eating behavior are increasingly turning to idealized media content, which in turn increases this problemFootnote 1 [3].

The consideration of media (content) in the development phase of a disturbed eating behavior primarily serves to develop preventive measures or intervention programs. One tries to find out which people are particularly vulnerable and which content could be particularly problematic in order to initiate appropriate measures, such as the prohibition or labeling of certain content. Some countries have already introduced a labeling requirement for processed advertising images, such as Israel and France. In Italy, the majority of model agencies have voluntarily committed not to employ models with an underweight BMI. Since the BMI was criticized as a criterion, a law came into force in France in 2017, according to which models can only be employed with a medical certificate in order to prevent pathological underweight in the industry. Even if an evaluation of these measures is still pending, experimental studies have shown that the presentation of models of normal weight compared to underweight models has a positive (or less negative) effect on one's own body feeling [18, 19].

Progress and coping phase: Influence of media content on those affected

Sick recipients

As described in the previous chapter, the main research to date has been whether the media can contribute to the development of an eating disorder in “healthy” people. In the area of ​​communication science research on media effects, there is a corresponding lack of studies that examine the effects of media content on people who are already ill. However, if one considers that eating disorders have one of the highest mortality rates of all mental illnesses [20], it seems urgent to focus research on affected people themselves.

One reason for this research gap is certainly also research-economic aspects. Sick people are a special target group that cannot be reached without a certain amount of effort; In addition, there are ethical considerations as to the extent to which vulnerable people can be confronted with potentially disease-aggravating content (in principle, however, the question also applies here whether and to what extent healthy people should be confronted with content that is believed to trigger disrupted eating behavior) . Even in the context of surveys, it is often stressful for those affected to talk about the topic. Nonetheless, research with sick people is also important in order to be able to assess the role of media in the development of eating disorders. Although post-hoc surveys and in-depth interviews cannot be used to establish causal relationships, they certainly help in the sense of method triangulation to underpin or contextualize experimental findings in order to better understand the role of the media or special content as potential triggers.

But the media can also play a central role in the course or coping with an eating disorder, both in a positive and in a negative sense. Here it is no longer just about the effect of media content, but also about its targeted use. Further methodological approaches could be the analysis of traces of use on the Internet (e.g. calling up certain information offers) or the evaluation of conversation logs (e.g. from forums on the topic). This avoids the problem of having to ask those affected directly about their illness, but of course ethical aspects such as B. data protection, are taken into account.

One of the few works that has dealt extensively with the role of media in eating disorders from a communication science perspective is Baumann's dissertation from 2009 [3]. In problem-centered in-depth interviews, the author spoke to sick girls and young women about the role of media (content) in different phases of their illness. Television in particular turned out to be the dominant medium, ahead of magazines and the Internet. Media content on the topics of beauty (ideal), nutrition and eating disorders themselves were mentioned frequently by the respondents. Overall, the role of the media was rated primarily negatively and their effect was more likely to be located at the beginning of the disease process, i.e. it was thematized as a potential trigger / intensifier. Above all, however, those affected reported a relatively targeted approach to content, for different reasons: "Media are used both to escape from the disease and as a means of coping and maintaining the symptoms" [3].

Therapist's point of view

In addition to the self-assessment of affected persons, the assessment by experts can offer an important additional perspective in order to assess the relevance of media (content) in the course of the disease and to better understand both constructive and destructive media action in this context. In her bachelor thesis in 2017, LochbihlerFootnote 2 Guided interviews conducted with therapists who specialize in the treatment of eating disorders. Above all, these emphasized the importance of the Internet in general and social media in particular, both in relation to constructive (i.e. disease-coping) and destructive (i.e. disease-aggravating) media action, with the latter seeming to predominate from the therapists' point of view.

A cited example are so-called Pro-Ana-Forums in which sick people share (sometimes life-threatening) tips on losing weight and hiding the disease and encourage each other to live out the eating disorder or the ideals of beauty behind it [21]. Platform operators such as Instagram and Youtube are trying to counteract these trends by blocking the relevant hashtags, but the therapists report that those affected are networked via private WhatsApp groups that are almost impossible to control.

In addition, “viral” trends that have recently emerged in social networks that propagate excessive leanness (e.g. [22]) are viewed as extremely problematic. In the case of potentially hazardous content, the therapists distinguish between content that is specific to the eating disorder and content that is not specific to eating disorders: The former includes phenomena such as pro-ana that are directly related to the disease; The second includes supposedly more neutral content that is not problematic for healthy people to the same extent (e.g. information about calories and fitness, entertaining formats such as "Germany’s Next Top Model") as for sick people, who, however, will process such content differently. However, the Internet also seems to be used constructively, for example for self-diagnosis or looking for therapeutic help and information about one's own illness.

In summary, the therapists' assessment shows a rather active use of media with a focus on online media, which is thematically closely related to the disease and is primarily driven by the motives for orientation and exchange. But the constant passive confrontation with media beauty ideals via advertising and other formats is also seen as problematic for the coping process. Formats such as "Germany’s Next Top Model" are viewed critically by the experts because they suggest that slimness and attractiveness are the only factors for success and recognition, especially among women.Consistent with the findings of Baumann [3], experts also see a strong focus on the part of the sick with media content that deals with the issues of appearance and weight. As already mentioned, such content is not only potentially disease-causing - people with the corresponding dispositions also increasingly turn to such content.

The media presentation of eating disorders and their effect on sick people

Both in the in-depth interviews with those affected [3] and in the therapist interviewsFootnote 3 It emerged that people with disturbed eating behavior also frequently use the media to find out about their own illness or to follow reports about it very closely. In this context, the question arises as to what role eating disorders actually play in the media as a clinical picture. In addition to looking at health information on the Internet, it is worth looking at mass media content simply because of the range. There are only a few and above all no current findings for the German-speaking area; Baumann et al. [4] were able to show in their content analysis of the press landscape from 2000 that the topic of eating disorders can be found in entertaining formats such as tabloids and women's magazines, but also quite often in quality newspapers. Anorexia is discussed much more frequently than other forms (although the number of people suffering from bulimia is usually much higher [1]).

It would also be interesting to see how the topic is presented and negotiated in other media genres, for example in entertaining formats such as current streaming series or films that are very well received by the relevant target group. This is where the potential for Entertainment education, i.e. the link between entertainment and educational content, is particularly high [23, 24].

In addition to the purely quantitative scope, it is of interest which image is drawn in the media of eating disorders in general and specific sub-forms (e.g. anorexia or bulimia). Even if hardly any studies are available for this special area, based on related research in the area of ​​health communication it can be assumed that especially dramatic and emotional individual cases find their way into the reporting [25]. On the one hand, this is due to the fact that tabloids / magazines primarily take up prominent or particularly drastic cases and carry them out in a dramatic manner [4]; On the other hand, however, findings from case study research [26] show that journalists * generally like to refer to individual cases when describing social phenomena / problems / illnesses and prefer particularly dramatic or emotional stories [27,28,29]. Baumann and colleagues [4] were also able to show in their content analysis that those affected themselves make up a large part of the actors represented in the reporting.

This raises the question of how such representations then in turn affect people affected by eating disorders. Based on the “model of reciprocal effects for social groups” [30, 31] and with the addition of the phenomenon of distortion of perception in media reception [32] as well as considerations on social comparison processes [13, 33], we would like to derive some empirically yet to be verified assumptions . The model of reciprocal effects deals with the effect of reporting on the persons represented there. Initially, the model was developed in relation to individuals [28], but later also applied to social groups such as migrants or right-wing extremists [30]. Based on the assumptions of the model and based on the findings presented above, it can be assumed that those affected will follow the reporting more intensively than others. Previous research suggests that sick people perceive the media presentation in a negatively distorted way, the more they identify with the group of sick people as a whole (hostile media phenomenon; [34]). At the same time, those affected make assumptions about how the representation of the disease in the media affects others - the more negatively the representation is perceived, the stronger the effects are generally assumed to have on other recipients [35, 36]. Based on this, they trace the behavior of those around them back to the media presentation and in turn align their own behavior with the perceived influence [37].

In previous research on the perceived media effect on third parties, the social proximity to others was primarily examined as an influencing variable; When examining mental illnesses, a further distinction appears to be necessary, namely between "initiated" (ie people who know about the illness) and "uninitiated". If the presentation of the illness in the media is perceived as very negative, this could increase the willingness to speak to the initiated (in order to justify oneself), but at the same time decrease the willingness to reveal oneself to other people.

A weakness of the reciprocal media effects model is that by focusing on social groups it largely hides effects on the self-image of the individual, but these are of enormous importance, especially in the case of mental illnesses such as eating disorders. Wood and colleagues [38] were able to show early on that people portrayed in the media who suffer from the same disease represent important standards of comparison for those affected (among other things because there is often no direct contact with other sick people). It therefore makes sense to expand the model to include the state of research on social comparison processes in the context of media use [13]. Accordingly, sick people compare the media presentation of the disease with their own situation and evaluate whether they are doing better, worse or similar. Depending on whether there are assimilation or contrast effects, this can have positive or negative consequences. Contrast effects come about when the situation of a comparison person does not appear to be attainable [39]: Upward comparisons with other sick people who are better off can then trigger frustration or depression, whereas downward comparisons with less well off persons lead to relief about one's own situation.Footnote 4 The latter then has an immediate positive effect on self-image, but could lead to the illness not being taken seriously enough (in the sense of "I'm not as bad as that person!" [13]). In addition, upward comparisons with other sufferers can also have a motivating effect, for example when it is shown how the eating disorder can be successfully overcome.

If you follow these considerations, it seems important to pay attention to success stories and to present positive role models when presenting individual cases in the media. At the level of self-perception, one can trigger motivating upward comparisons, give the sick hope and motivate them to tackle the disease. At the same time, a positive image of people with eating disorders and their handling of the disease is drawn, which can have both direct and indirect effects on the perception of the disease in society and rather motivates those affected to deal openly with their problems.

What should be avoided in any case is the presentation of potential triggers to prevent imitation - i.e. reporting on specific lean trends in social networks or giving examples of dangerous measures that are exchanged in pro-ana forums. The problem of such representations has already been increasingly addressed in the context of depression and suicide (and accordingly also anchored in journalistic ethical guidelines), but is rarely discussed in other forms of mental illness.

Conclusion and discussion

The media play an important role in the context of an eating disorder - from the point of view of those affected, the therapist and, last but not least, probably also in the perception of the public. They are potential contributors to eating disordered behavior, as many research results have already shown. But above all, they also have an influence in the course and coping phase of the disease, which, however, has not been focused enough in research. As shown by the findings of Baumann [3], among other things, the media, in addition to a more passive confrontation, are also used specifically during the course of the disease, both to maintain the symptoms (destructive media action) and to deal with the disease cope with (constructive media action). Both strategies need to be researched more intensively in terms of causes and consequences in order to support those affected in the course of the disease.

Destructive media trends such as Pro-Ana, but also less drastic forms such as an Instagram feed that is strongly geared towards beauty or slimness or casting and dating formats on television can be described in terms of their risk potential and in the context of therapy or in context be thematized by prevention or intervention programs. However, the focus should not be solely on the question of how those affected deal with potentially problematic content or how they can avoid it, but which media content can also have a health-promoting effect. In this respect, both research and social discourse should be rethought: In addition to the problematic sides of the media, their potential positive role should also be considered. Research should shed light on what constructive media action can look like in the context of an eating disorder and how it can be brought closer to the patient. In therapeutic practice, this is already being discussed more and moreFootnote 5However, basic research on this is still largely lacking.

In addition, from a communication science perspective, it seems important to deal more with the representation of eating disorders in the media, in both informative and entertaining formats. On the one hand, this can provide information about the (distorted) image of the disease in our society. On the other hand, sick people are also recipients of such content and, as previous findings suggest, this group in particular follows such reports or representations particularly intensively.

Little is known about the role of online offers and social networks in the course of an eating disorder; there is still a need for research here. Like Lochbihler's findingsFootnote 6 suggest, such offers can have both a positive and a negative influence on the course of the disease. The possibilities are extensive here, especially due to the active part of the user. Social networks in particular can play an intensifying role in the context of an eating disorder due to their idealized representations of beauty. Here, the development of media competence training for schools or intervention programs is important in order to counteract potentially negative effects [40]. At the same time, sick people can exchange ideas or learn to deal actively with it by sharing the disease.


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