Social media interventions for non-communicable diseases: a call for a holistic approach considering eating disorders,mental health and wellbeing

Non-communicable diseases (NCDs) are the leading cause of death globally, with cardiovascular disease, cancer, diabetes and mental illnesses posing an enormous public health burden. ¹ Modifiable risk factors for NCDs include tobacco smoking, physical inactivity and harmful alcohol consumption. ¹ These risk factors are disproportionately more common among those with poor mental health. ²

Around 4 billion people use social media ³ ; each user accesses an average of 6.7 platforms. ³ While social media was initially designed to offer virtual human connection, ³ its ubiquity has often led to suggestions that it should become a market access strategy for health improvement worldwide. ⁴ However, there has been little discussion about the negative psychological implications of using social media as a health intervention, ³ and how these compare to the benefits of NCD risk reduction. Such consideration is vital if we are to understand the net benefit of social media-based interventions.

Social media interventions for NCD risk reduction often focus on influencing exercise and diet behaviours to reduce high body mass index (BMI) and proportions of body fat.^4–6 Bender et al. reported the feasibility of a mobile health intervention for weight loss among Filipino Americans with type 2 diabetes mellitus. ⁵ Dorje et al. also reported a weight-loss WeChat intervention effective in China among those with coronary heart disease. ⁶ However, there is a paucity of literature exploring the longitudinal psychological impact that constant exposure to health promotion messages focusing on weight loss may contribute to. If found to facilitate adverse disordered eating behaviours, this creates a separate global health challenge.

Individuals with overweight or obese body habitus are often the target of social media interventions and public health campaigns.^4,7 In England, around 64% of adults may be classified as overweight or obese. ⁸ Studies suggest that individuals classified as overweight or obese are two-times more at risk of disordered eating behaviours, including diet pill use, laxative abuse or purging. ⁹ Over one-third of patients presenting for treatment of restrictive eating disorders have a history of being overweight or obese. ⁷ This pre-established link is likely due to widespread social stigma around increased body weight, leading overweight or obese individuals to take extreme measures in attempts to reduce their weight. ⁷ Early identification and treatment of restrictive eating disorders predict a good prognosis. ¹⁰ With these individuals starting at a higher BMI, it frequently takes much longer to detect eating disorders, contributing to a poorer prognosis. ⁷

With the rising prevalence of both eating disorders and obesity, the association must remain at the forefront of public health professionals' and policymakers’ minds. Public health interventions involving weight management must adopt a more holistic approach by considering the potentially harmful mental health implications of these strategies. Collaborative care models that integrate actions on NCD risk reduction with mental health care are crucial for safer weight loss programs. ¹¹ This integration requires investment in human resources and services; ¹¹ recruiting and training lay health workers alongside specialised team leaders addresses this practically. ¹¹

Other eating disorders, such as binge eating disorder and night-eating syndrome, may lead to weight gain. It is suggested that 5–15% of individuals with obesity suffer from one of these disorders. ¹² NCDs, such as type 2 diabetes mellitus, are common co-morbidities in this cohort. ¹² Randomised controlled trials have demonstrated that those affected would benefit more from evidence-based treatment, including pharmacological management and cognitive behavioural therapy, than social media interventions. ¹²

Several aspects of diabetes management may increase the risk of eating disorders. ¹³ Diabulimia is an eating disorder observed when someone with type 1 diabetes mellitus (T1DM) intentionally restricts their insulin administration to lose weight. ¹³ Almost 10% of those with T1DM would screen positive for diabulimia, and approximately 30% of the same patients report withholding insulin at least once with the aim of weight loss. ¹³ Diabulimia is known to lead to severe diabetic complications and hospital admissions. ¹⁴ While T1DM remains a global NCD, further research is needed to ensure that social media interventions heavily focused on weight loss are not negatively impacting morbidity and mortality.

More widely, management for common diabetes types emphasises controlling quantities of different food groups from the outset. ¹⁴ This focus may manifest as a fixation, increasing anxiety and leading to the emergence of disordered behaviours, such as cycles of binging and restricting. ¹⁴ A thorough consideration of the complex interrelationships between eating behaviour, metabolic control and insulin administration in all types of diabetes calls for mindful interventions co-produced between diabetes and psychiatric specialists with appropriate input from patients. Over a decade ago, King’s College Hospital (in London, UK) launched the ‘3 Dimensions of Care For Diabetes’, a scheme integrating psychological, social and medical services across two of London’s boroughs. ¹⁵ The intervention was considered highly effective and gained attention from policymakers in the UK and researchers worldwide. ¹⁵

Severe mental illness is often under-considered as an NCD. While the links between physical health NCDs and various eating disorders are common, it is equally important to dissect the intricate interplays of mental health NCDs. Severe mental illness describes psychological concerns that severely impair functional and occupational activities; these illnesses affect half a million adults in England.^16,17 Severe mental illness frequently pertains to schizophrenia and bipolar disorder but also includes anxiety disorders and personality disorders, as well as eating disorders.^16,18 Severe mental illness significantly increases the risk of better-recognised physical health NCDs and a poorer prognosis from these co-morbidities. ¹⁶

Further evidence is needed to understand the balance between social media interventions improving physical NCD risk factors and increasing severe mental illness. Among adults, the average daily social media use globally is 145 minutes. ¹⁹ As such, these social media interventions can easily be incorrectly promoted to someone diagnosed with a severe and enduring eating disorder. Exposure to such intervention may increase body dissatisfaction and disordered eating in both those with pre-existing body image and eating concerns or lead to their development in vulnerable individuals. ²⁰ In promoting weight-loss-oriented social media recommendations, public health professionals and policymakers must take accountability for the role of these interventions in exacerbating psychological concerns. Social media interventions for NCD risk reduction must be sensitively targeted to the correct subgroups and identify those adversely affected within target subgroups.

In practice, the public health interventions explored in pilot studies use a combination of pre-existing social media platforms and those which have been purpose-built. Systematic reviews show that increased use of social media and frequency of social media use are associated with body dissatisfaction and disordered eating. ²¹ Persistent exposure may become distressing, and the pressure to conform to such expectations can lead individuals to adopt dangerous eating habits.^20,21 Given the rapid increase in social media usage, ¹⁹ policy and practice initiatives should carefully consider the unique strengths and limitations of each platform when designing interventions.

Additionally, social media strategies often fail to acknowledge or address social or commercial determinants of health, shifting blame away from wider systemic issues. The consequences of calorie-dense foods sold at lower prices than fruit or vegetables, particularly for those of low socioeconomic status, the effects of a reduction in manual labour job opportunities due to advancements in workplace technologies and the urban design of large cities requiring vehicle transportation are grossly overlooked. ²²

In summary, despite extensive reach, social media interventions, as a public health strategy, face important limitations. Generic diet and exercise-based social media interventions for NCD risk reduction should be balanced with considerations regarding the negative impact on psychological health, body image and disordered eating. The complex yet inherent links between NCDs and numerous eating disorders should be addressed by healthcare and public health professionals. With ever-evolving social media platforms, longitudinal research on the psychological impacts of social media interventions must be conducted on the full diversity of patients affected, and professionals must employ tailored approaches aimed at specific intersectional groups alongside integrated mental health awareness and support. Co-designing these interventions with relevant stakeholders would ensure nuances are adequately understood and that population health interventions using social media achieve adequate risk reduction of NCDs without unintended harm.