Introduction

Increased rapid developments in technology and communication in the 21^st century, the need to access information and use it effectively has become an integral part of daily life^1,2. Media, the name was given to all of the major communication and broadcasting tools while defining “whole communication environment”³; social media, on the other hand, can be defined as a user-based form of electronic communication such as websites for social networking where users build online communities to share information; to express their thoughts and personal messages; to discuss ideas and other content^4,5. Social media is at the same time an electronic form of communication that enables users to produce and use content, providing social interaction, and appointment⁶. Communication of individuals born in the digital world (ages 15-24) takes place on social media or social networks⁷. It was found that 13% of young people in Turkey spent more than six hours on social media, 86% of them connect to social media at least once a day⁸.

Whereas eating disorder studies conducted to date were examined, although they did not show a clear consistency, nutrition and dietetics students were more risk-prone than others^9-13. The knowledge of nutrients, weight gain and body compositions, and/or thought of appearance effect on their future careers are identified as factors that increase the risk^14,15. Given the high popularity of social media among young adults who spends much time on these platforms, nutrition and dietetic students attract attention by sharing health-related nutrition information, food preparation, recipe collection, or recipe preparation for others. Social media, on the other hand, is a platform where these posts are made the most and its usage is becoming widespread day by day. Besides nutrition and dietetics students are a more remarkable group in terms of nutritional behaviors due to the education they receive, younger female adults are more susceptible to eating disorders. A review¹⁶ aimed to find epidemiology of eating disorders in Europe found that 2.0-3.0% of women reported eating disorders while men reported 0.3-0.7%. Therefore, in most of the nutrition studies, young women are selected as target groups and examined in terms of nutritional properties.

The aim of the present research is to determine the tendency, frequency, and duration of social media membership in the daily lives of female students in the Nutrition and Dietetics Department and to examine the effects of media on BMI and eating disorder.

Material and methods

This cross-sectional study was carried out with the students of the Department of Nutrition and Dietetics, who studied at universities in Istanbul between November 2017 and May 2018. 1280 participants who accepted to participate voluntarily from 2^nd, 3^rd, and 4^th grade female students were included in the study. Exclusion criteria were: being 1^st grade students due to a lack of professional knowledge. Participants, who did not have a social media account (n=23) and who did not complete the questionnaire form (n=9) were excluded, and the final number of participants was 1248. Ethical approval was taken from Bilgi University Ethical Committee (2017-50016-26).

A face-to-face questionnaire form consisting of three parts was applied to participants. The first part is socio-demographic characteristics that include information about height and weight, diet and physical activity status, social media use based on their statements; the second part is the Social Media Attitude Scale (SMA) for determining a person's social media attitude; the third part was the Eating Attitudes Test (EAT-40) scale was used to determine eating disorders.

The SMA was developed by Argın and Otrar (2015), aimed to measure individuals' attitudes towards social media¹⁷. It is a 5-point Likert-type with 23 items. Items 3, 7, 11, 14, 22, and 23 are reverse coded because they are negative. The minimum score is 23, and the maximum score is 115¹⁷. Finally, the average scores of the data between 1.0-2.33 were evaluated as “negative attitude”, those between 2.34 and 3.66 are considered as “partially positive attitude” and those between 3.67 and 5 is “positive attitude”¹⁸.

Eating attitude is a self-report scale EAT-40 was developed by Garner and Garfinkel in 1979 and it is a general screening measure for abnormal eating attitudes¹⁹. EAT-40 test is a 6-point Likert type scale consisting of 40 items and the cut-off score was determined to be 30¹⁹. The scale's validity and reliability to Turkish were made by Savaşır and Erol²⁰. Those who obtain 30 or more scores at risk of eating disorders, but the test results are not sufficient for a definitive diagnosis.

Windows SPSS 21.0 Statistical Software was used for the statistical evaluation of the data. Mean, standard deviation (SD), minimum, and maximum values were determined to evaluate the data to be obtained as a result of the sociodemographic questionnaire. Categorical data in the questionnaire were evaluated as number (n) and percentage (%). The significance of the difference between the averages of the data that showed normal distribution was examined in two independent groups with the t-test. For more than two groups, it was analyzed by a one-way analysis of variance. For non-normally distributed data, Chi-square and Kruskal-Wallis as nonparametric tests were applied. The margin of error is p=0.05 and it has been worked with 95% confidence.

Results

The mean age of the participants was 20.7±2.2 years. The average body weight was 56.9±8.2 kg, the average height was 165.0±5.9 cm, and the average BMI was 20.9±2.7 kg/m². According to BMI classification, most (69.2%) of the participants were normal, 20% were overweight, 9.7% underweight, and 1.1% were obese. 42.6% of the participants have never been on a diet. At the same time, 58.3% of the participants think that they have a moderate problem with eating. Based on self-reported physical activity status most of (66.2%) the participants were active several times in a month. When the EAT-40 scores of the participants are analyzed, it has been found that 64.3% of them had a normal eating attitude. According to the SMA scale, 89.6% were found to be partial positive attitudes (Table 1).

Information about the social media usage of the participants was given in Table 2. According to this information, 77.8% of the participants reported that they have been using social media for 4 years and more, 65.1% have used social media many times, and 42.5% spent 11-30 minutes on social media in a day.

93.7% of the abnormal eating attitude group showed partial positive attitude towards social media, 0.4% showed negative attitudes; while 87.3% of the group normal eating attitude showed partial positive attitudes, 2.1% showed negative attitudes (p=0.001) (Table 3).

When the eating attitude test scores and the frequency of social media usage of the participants were evaluated, there was a significant difference between the groups (p=0.002). It was observed that the differences were significant between the always online group with the groups using social media 2 or 3 times a week (p=0.019), 1 or 2 times a day (p=0.007), and multiple times a day (p<0.001), respectively (Table 4).

Information on the comparison of the participatory characteristics of the participants and EAT-40 and SMA scores are given in Table 5. The entire group with the abnormal eating attitude has social media membership, 39.5% of them spend 11-30 minutes on social media during the day (p<0.05). There was no statistically significant difference between the social media attitude of the participants and their BMI, diet, and thought of an eating problem (p>0.05).

Discussion

In this study, it was aimed to investigate the relationship between the media usage habits of female students of nutrition and dietetics in Istanbul and the risk of eating attitude and behavior. A study was conducted by Kim (2015) to evaluate eating attitudes of female university students, the mean age and BMI of the participants were found as 20.0±1.8 years, 20.1±2.2 kg/m², respectively²¹. According to the findings obtained from this study, the mean of age (20.7±2.2 years) and mean of BMI (20.9±2.7 kg/m²) were the same as the previous study. Percentages of individuals who were normal according to BMI classification were found to be similar to the results of Woo et al. (2014)²². According to the 2018 Turkey Demographic and Health Survey report, women in the 20-29 age range in Turkey were found a mean BMI of 25.1, and 50.7% of them have normal BMI²³. Similar to our study, in another study conducted with female students on nutrition and dietetics 77.2% of them were found to be normal BMI²⁴. In our current study, it is thought that the reason for the lower mean of BMI is due to the university population of the younger age group.

In 2018, the number of Internet users worldwide was 4.021 billion with an annual increase of 7%, the number of social media users was 3,196 billion, with an annual increase of 13%²⁵. According to TurkStat data; Computer and Internet using rates in Turkey were 50.6% and 65.5% respectively in female individuals in the 16-74 age group in 2018²⁶. When the frequency of social media use was examined in our study, it was seen that 65.1% of the participants used social media.

In studies conducted to measure the eating attitudes and behaviors of Turkish university students, it was observed that the rate of eating behavior disorder of female individuals ranged from 6.6% to 13.4%^27,28. In another study conducted in the following years with the participation of 314 female university students, the average of EAT-40 test score was found 14.38 and the rate of eating disorders by 8%²⁹. In the current study, the risk of eating disorders was observed in 35.7% of the participants, and the mean of the EAT-40 score was found at 20.8 ± 14.3. In light of these data, we observe that the risk of eating attitudes increases with female university students in our country over time.

In a study examining the eating attitude components of university students, the participants reported that they were influenced by the media³⁰. General Problematic Internet Usage Scale (GPIUS) was applied to 383 university students (70.2% women) with an average age of 23.8, and it was found that body esteem indicators mediate the relationship between the use of social networking sites and eating disorders. After more use of social media sites, it causes serious weight and appearance dissatisfaction associated with eating disorder³¹. In our study, when the participants' EAT-40 scores and the frequency of social media usage were evaluated, a difference was found between the group that is always online and the groups that use social media 1-2 times or 1-3 times a week. It can be said that the risk of eating disorders increases in proportion to the time spent on social media.

Studies examining the relationship between BMI and social media use are limited. While some of these studies had an effect of social media on BMI^32-34, others indicated no significant associations. In line with studies that did not find a relationship^35,36, no significant relationship was found between the social media attitudes of the participants and their BMI in the present study. It is predicted that several reasons may have been effective in this regard. One of these reasons is that nutrition and dietetics students may be using social media for personal or educational reasons³⁷. Sampasa-Kanyinga et al. found a relationship between social media and body mass index in a study conducted on male adolescents³⁵. Another reason is that our group in the current study consists only of the female population.

The use of only women is a strong aspect, as dietetics professionals and students are consisting mostly of women, thereby they represent the vast majority of the group. EAT-40 and anthropometric measurements are based on their statements, and high nutritional training may cause biased responses. Despite its limitations, this study has quite a large sample size, validated, and reliable measurement items. The present study was conducted in Istanbul which is represented a small sample of Turkey (18.7% of the whole population).

Given the rapid rise in social media use on gender can be improved by adding male participants to the study. Concurrently, comparing the nutrition and dietetics departments with others will enable a better understanding of the effects of social media on nutrition and dietetics students.

Conclusions

Due to its increasingly widespread use and the relation between health, social media usage deserves further relevance in the field of nutrition dietetics. The current study, the effect of social media, in the formation of eating disorders, was emphasized. Findings suggest that while there was a significant relationship between the effects of media use on eating disorders and there was no significant effect on BMI. In addition to conducting advanced research to better understand the role of social media among nutrition dietetics students, as a consequence that from student to professional education of nutrition and dietetics social media appears crucial, it may be a useful approach to design and present a curriculum for instructors on the nutritional attitudes, nutritional status and professional practices of social media with an evidence-based approach in trainings.