Brittany Taylor-Whitmer

June 20, 2017

APN 601

Research Prospectus

Introduction

Social network sites (SNS) are defined as websites and web-based apps where individuals can

create a profile to develop a set of connections with other users within the site.1 Although these

sites are a relatively new concept, the majority of American’s participate in at least one SNS.

Based on a 2016 review, 86% of Americans use the internet, with 8 out of 10 of these users

participating in social media.2 There are hundreds of SNS available, all with varying designs and

purposes. One of the more recent developments in SNS is health-based communities. These

communities first started with health-specific sites and apps, such as Fitbit and Myfitnesspal3.

These devices allow users to not only track their health-related information, but interact and

compete with other users. More recently, generic SNS like Facebook and Instagram have

developed health-based communities within them. Thousands of pages dedicated to providing

health tips and encouraging users to participate in nutrition or fitness challenges have been

created.

While a movement towards healthy lifestyles initially seems positive, there are growing

concerns about obsessive health behaviors. These concerns led Dr. Steven Bratman to develop

the term Orthorexia Nervosa in 1996 as a way to describe patients he was treating that had an

unusual obsession with eating healthy5. To date, a formal definition and criteria for diagnosis are

still in development6. One particular characteristic that differentiates Orthorexia Nervosa from

healthy eating is when concern for eating healthy overrules other aspects of life. Behaviors can

include eliminating foods or food groups, inability to let go of food restrictions for special

occasions, and anxiety about foods deemed unacceptable5.

Statement of Problem/Question

Because Orthorexia Nervosa is in its infancy of definition, much still needs to be understood

about the disorder. While preliminary research has posed a connection between SNS and eating

disorders, little information exists on specifically Orthorexia Nervosa8-12. It has also not been

determined if certain aspects of SNS are more damaging than others. Therefore, inductive

research must be conducted in order to provide a foundation for theory in this area. The purpose

of this research is to determine if involvement in SNS-based health communities is linked to

symptoms of Orthorexia Nervosa. Of particular interest are adult women of Generation Y, who

are most likely to be involved in SNS and SNS-based health communities8-12.

The research question is as follows:

Is involvement in SNS health-based communities correlated with symptoms of Orthorexia

Nervosa in American women ages 18-22?

Literature Review:

A significant amount of prior research has shown a link between media and body image

and/or poor health habits, most of which has focused on television and magazine-based

platforms6. It is only within the past few years that research has begun to focus on the potential

effects of online media, and SNS in particular.

Research on social media use and body image and/or poor health habits predominantly

focuses on females, in particular of college age8-9. A study conducted by Meier et al. also

reviewed girls ages 12-1810. Carrotte et al. did not select for exclusively females, but only

26.87% of participants were male. It also found that significantly less males participated in

health-communities compared to females11. Similarly, Turner et al. included all genders, with

only 3.2% being male, and 0.6% identify as other12. The young, female population is particularly

useful for SNS research because they are most comfortable with and involved in SNS and health-

communities. They are also most susceptible to poor body image and/or health habits due to

media5.

The majority of research available has focused on the effects of Facebook. Meier et al. found

that although overall Facebook use is not significantly correlated to negative body image,

increased use of Facebook involving photos was significantly correlated with poor body image10.

Mabe et al. found that Facebook use increased anxiety related to body image in comparison to

other internet use8. Smith et al. found that maladaptive Facebook use, such as activity leading to

social comparisons, is correlated with increased body dissatisfaction9.

While most research focuses on Facebook use, one study looked at who is most likely to

follow health and fitness-related content on multiple forms of SNS11. Carrotte et al found that

37.76% of participants followed at least one health and fitness-related page or group on SNS.

Predictors for following these types of pages were identified as young females in rural areas with

no post-high school education11.

Disordered eating is a concerning potential outcome of SNS use. Carrotte et al also

determined that those with reported eating disorders or misuse of laxatives/detoxes were more

likely to participate in health and fitness-related content on SNS11. Mabe et al. found that

increased use of Facebook was linked to increased disordered eating symptoms8. Smith et al

found a connection between maladaptive Facebook use and increased bulimic symptoms9.

Turner et al. conducted one of the only studies to date looking at the effect of SNS on symptoms

of Orthorexia Nervosa. It concluded that out of multiple SNS evaluated, Instagram use is

significantly correlated to Orthorexia Nervosa symptoms12.

While previous research regarding SNS use endorses a connection to negative health habits

and eating disorders, there is not yet enough to build valid theory. Additionally, very little

research exists on Orthorexia Nervosa. To the best knowledge, no studies have yet examined

SNS-based health communities’ effect on Orthorexia Nervosa symptoms.

Methodology

I. Participants

Based on previous research and the use of G*Power’s t test: correlation point biserial model,

required sample size is determined to be 614. Recruitment will be done via online advertisements

placed on SNS sites, including Facebook, Instagram, Twitter, and Pinterest. In order to this, a

business account will be made for the study on each SNS. By using the business account settings,

advertisements can be purchased. Payment can be done via cost per click (CPC) – a cost each

time someone clicks the advertisment13. Based on average pricing, CPC would be $1.0014.

Because response rate of 30% is expected with online surveys, 2046 clicks are expected to be

necessary15. Therefore, a budget of approximately $2050 will be required. Compared to other

survey methods, this is determined to be the least expensive15. Advertisement example can be

seen in figure 1. Inclusion criteria includes: female, ages 18-22, U.S. citizen, and involvement in

at least one SNS-based health community. When advertising on SNS, parameters can be set for a

specific audience and those who search specific key words13. This will assist in targeting the

appropriate participants by setting age/gender/citizenship parameters, and targeting key word

searches such as “diet”, “cleanse”, and “fitness”.

II. Data Collection

All participants will be asked to fill out and submit an online survey. This can be completef

from their home computer, laptop, or smartphone, with no need to travel to a specific study

location. The first part of the survey will be developed by the research team using

SurveyGizmo’s data analysis survey software. Initial study questions are outlined in figure 2.

This part of the survey will be pilot-tested by 10 sample participants meeting inclusion criteria.

This will ensure directions and questions are clear, determine an approximate expected length of

time required, and identify any errors in technology or site layout. Cronbach’s Alpha will be

used on pilot test results to ensure a reliability coefficient of .70 or higher is obtained. These

questions will then be adapted and formalized based on the pilot testing results. Information

gathered from this part of the survey will include demographics, number of SNS and SNS-based

health communities utilized, and approximate amount of time spent on these sites. The second

part of the survey will be the questions from the ORTO-15. These 15 questions are the current

approved survey used for Orthorexia Diagnosis, as seen in figure 316.

III. Analysis

The ORTO-15 score will be calculated according to the supplied scoring grid, with a score of

<40 indicating an Orthorexia Nervosa diagnosis16.

Answers on time spent on SNS and SNS-based health communities will be converted into a

numerical value, as follows:

“A significant amount” = 5, “A lot” = 4, “A moderate amount” = 3, “A little” = 2, “None” = 1.

Much like previous studies, the data provided on social media for this study is ordinal and

nonparametric. Therefore, Spearman’s rank order correlation will be used to determine if a

relationship exists between ORTO-15 scores and SNS use, as well as ORTO-15 scores and SNS-

based health community use. This will be determined by plotting individual’s ORTO-15 score

versus each use of SNS and SNS-based health communities, as seen in table 1. This will result in

10 graphs in all. The slope of the fitted line of the scatterplot will determine if correlation is

positive or negative. Negative relationships will be shown by a downward slope, while positive

relationships will be down by an upwards slope.

Based on the data of these graphs, the correlation coefficient will be calculated and will be

added to tables, as seen in table 2. Each correlation coefficient will then be tested for significance

by comparing the linear regression t-test p-value of each correlation coefficient to a significance

level of p < 0.01 and p < 0.05. These tests will determine if a significant correlation exists

between SNS and/or SNS-based health community usage and symptoms of Orthorexia Nervosa.

As the concept of SNS-based heath communities’ effect on Orthorexia Nervosa has yet to be

studied, initial research, such as that described in this study design, needs to be conducted in

order to determine if a correlation exists.

IV. Ethical Considerations

Respect for persons will be acknowledged by having all participants sign an informed

consent form before submitting the survey. Participants will be informed that no identifiable

information will be retained after data collections is complete, and that they are participating

in research relating to SNS and SNS-based health community use and disordered eating

patterns. The implication that a connection may exist between these may provide a burden or

harm to the participants. Beneficence will be addressed by ensuring understanding of the

purpose of the research, and providing resources for information and/or treatment options if a

participant expresses concerns regarding Orthorexia Nervosa symptoms. Participants will also

be informed that participation is voluntary and that confidentiality will be maintained. Justice

will be maintained by having all participants complete the same survey. Although the

research involves human subjects, it is exempt from IRB review as it only involves data

collection from surveys that cannot be traced back to individual participants.

V. Proposed Timeline

Month 0-1: Development and approval for ads, initial pilot study recruitment

Month 2-4: Pilot testing of survey; revision and approval of final survey

Month 5-9: Recruitment of participants, survey distribution, and data collection

Month 10-12: Data analysis and preparation of formal research

Discussion of Proposed Research

Orthorexia Nervosa is a relatively new disorder, still in the process of being formally

defined4. While an obsession with healthy eating may not seem like a large concern, Orthorexia

Nervosa can be fatal. The first death was reported in 2003, when an Orthorexic patient of Dr.

Bratman’s died from cardiac complications due to food restrictions6. It was at this point that the

severity of Orthorexia Nervosa became apparent. Because research on the effects social

networking sites has raised concerns regarding body image and disordered eating, it needs to be

asked if a connection exists between SNS and SNS-based health communities and symptoms of

Orthorexia Nervosa.

Because this study relies on participant survey responses, results may be skewed by the

participant answers. Answers may be inaccurate due to misunderstanding or misinterpretation of

the questions. They also may be intentionally inaccurate, due to participants wanting to portray

themselves a certain way or answering questions based on what they feel the study is looking for.

Because eating disorders can be a sensitive topic, collecting fully reliable data may be difficult.

The length of the survey may also compromise results, as participants may answer less

thoughtfully in order to accelerate the process.

This study looks at a specific population in order to target those with high social media and

SNS-based health community use. While this provides information on what is suspected to be

the most prevalent population, further research will be required to examine the effects of SNS

and SNS-based health communities on the population as a whole. This study also only examines

the correlation between SNS and SNS-based health communities and Orthorexia Nervosa. It will

not be able to explain why the correlation does or does not exist, or imply causation. Further

research is necessary in order to understand the correlation and potential confounders before

causation can be considered. Finally, the design is cross-sectional, providing only a snapshot

look into the correlation. Longitudinal studies will need to be done to examine the effects of SNS

and SNS-based health communities over time.

This research will provide more specific information on habits correlated with symptoms of

Orthorexia Nervosa. If the correlation is established, further research can be conducted into the

mechanisms behind the effect of SNS-based health communities. This information can then be

used to better understand those with Orthorexia Nervosa, and help to develop more effective

treatment plans.

Bibliography:

1. Boyd DM, Ellison NB. Social network sites: definition, history, and scholarship. J

Comput Mediat Commun. 2007;13.

2. Greenwood S, Perrin A, Duggan M. Social media update 2016. Pew Research Center.

http://www.pewinternet.org/2016/11/11/social-media-update-2016/ . Updated November

11, 2016. Accessed June 10, 2017.

3. Valentine A. The 6 best fitness apps. http://blog.proto.io/6-best-fitness-apps/. Updated

April 6, 2017. Accessed June 10, 2017.

4. Wikepedia. List of social networking websites.

https://en.wikipedia.org/wiki/List_of_social_networking_websites. Updated June 13,

2017. Accessed June 17, 2017.

5. Bratman, S. What is orthorexia? http://www.orthorexia.com/what-is-orthorexia/ Updated

January 23, 2014. Accessed June 10, 2017.

6. Bratman, S. Orthorexia: an update. http://www.orthorexia.com/orthorexia-an-update/.

Updated February 5 2016. Accessed June 10, 2017.

7. Holmstrom, AJ. The effects of the media on body image: a meta-analysis. J Broadcast

Electron Media.. 2004;48:196.

8. Smith AR, Hames JL, Joiner TE. Status update: maladaptive facebook usage predicts

increases in body dissatisfaction and bulimic symptoms. J Affect Disord. 2013;149:235-

240

9. Mabe AG, Forney JK, Keel Pk. Do you “like” my photo? Facebook use maintains eating

disorder risk. Int J Eat Disord.. 2014;47:516-523.

10. Meier EP, Gray J. Facebook photo activity associated with body image disturbance in

adolescent girls. Cyberpsychol Behavior Soc Netw. 2014;17: 199-206.

11. Carrotte ER, Vella AM, Lim MSC. Predictors of “liking” three types of health and

fitness-related content on social media: a cross-sectional study. J Med Internet Res.

2015;17:101-114.

12. Turner PG, Lefevre CE. Instagram use is linked to increased symptoms of orthorexia

nervosa. Eat Weight Disord. 2017;22:277-284.

13. Marsan J. How much does facebook advertising cost?

http://fitsmallbusiness.com/how-much-does-facebook-advertising-cost/ . Updated

September 1, 2016. Accessed June 20, 2017.

14. Torr D. How to advertise on facebook: a beginner’s guide.

https://blog.hootsuite.com/how-to-advertise-on-facebook/ Updated February 7, 2017.

Accessed June 20, 2017.

15. Forister JG, Blessing JD. Introduction to research and medical literature for health

professionals. Burlington, MA: Jones & Bartlett Learning; 2016.

16. Donini LM, Marsili D, Imbraile M, Canella C. Orthorexia nervosa: validation of a

diagnosis questionnaire. Eating Weight Disord. 2005;10:e28-e32.

Figure 1. Recruitment Advertisement

University of New England

Volunteers Wanted for a Research Study

We are looking to research the effects of Social Network-based health communities on

individual’s health habits.

We are looking for: females ages 18-22 who are U.S. citizens and involved in at least one online

health community.

All you need to do is fill out and submit two online surveys, taking up less than 10 minutes of

your time.

This research is conducted under the direction of (list principle investigator, title & department)

To learn more, email (list e-mail address)

Figure 2. SNS use survey

1. What is your gender?

Male Female Other

2. What is your year of birth?

______________________

3. What is your email address?

______________________

4. How much time do you spend on Facebook?

A significant amount A lot A moderate amount A little None

5. While on Facebook, how much time do you spend on health community pages? (i.e.

weight loss, fitness motivation, cleanses, detox, diet, weight loss challenges, fitness

challenges, etc.)

A significant amount a lot A moderate amount A little None

6. How much time do you spend on Instagram?

A significant amount A lot A moderate amount A little None

7. While on Instagram, how much time do you spend on health community pages? (i.e.

weight loss, fitness motivation, cleanses, detox, diet, weight loss challenges, fitness

challenges, etc.)

A significant amount a lot A moderate amount A little None

8. How much time do you spend on Twitter?

A significant amount A lot A moderate amount A little None

9. While on Twitter, how much time do you spend on health community pages? (i.e. weight

loss, fitness motivation, cleanses, detox, diet, weight loss challenges, fitness challenges,

etc.)

A significant amount a lot A moderate amount A little None

10. How much time do you spend on Pinterest?

A significant amount A lot A moderate amount A little None

11. While on Pinterest, how much time do you spend on health community pages? (i.e.

weight loss, fitness motivation, cleanses, detox, diet, weight loss challenges, fitness

challenges, etc.)

A significant amount a lot A moderate amount A little None

12. How much time do you spend on other social networking sites?

A significant amount A lot A moderate amount A little None

13. While on other social networking sites, how much time do you spend on health

community pages? (i.e. weight loss, fitness motivation, cleanses, detox, diet, weight loss

challenges, fitness challenges, etc.)

A significant amount a lot A moderate amount A little None

Figure 3. ORTO-15 Survey

Donini LM, Marsili D, Imbraile M, Canella C. Orthorexia nervosa: validation of a

diagnosis questionnaire. Eating Weight Disord. 10;e28-e32. June 2005.

Table 1. Example scatterplot

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.505

101520253035404550

Correlation of time on Facebook-based health communities and ORTO-15 scores

Amount of time on Facebook-based health communities

ORT

O-1

6 Sc

ores

Table 2. Correlation Coefficient Tables

Overall Facebook use Facebook health

community use

ORTO-15 Score

Overall Instagram use Instagram health

community use

ORTO-15 Score

Overall Twitter use Twitter health community

use

ORTO-15 Score

Overall Pinterest use Pinterest health community

use

ORTO-15 Score

Overall other SNS use Other SNS health

community use

ORTO-15 Score