Background and aims: Social media increasingly shapes body image by promoting often unattainable beauty ideals. Concurrently, targeted online marketing of image- and performance-enhancing drugs (IPEDs) exploits these vulnerabilities, intensifying anxiety and fostering maladaptive behaviours such as problematic usage of the internet (PUI), compulsive exercise, and IPEDs consumption. This study explores these behaviours across nine countries and examines how PUI, excessive exercise, and IPEDs use predict appearance anxiety, aiming to inform targeted prevention strategies for at-risk populations. Methods: A total of 3,514 participants from nine countries completed a web-based survey assessing sociodemographic data, appearance anxiety (AAI), problematic internet use (PIUQ-9), excessive exercise (EAI-R), and IPEDs intake. Results: Appearance-related anxiety was observed in 12% of the participants, with the highest prevalence in Mexico (20.7%), Japan (13.8%) and Italy (13.6%). Median PUI scores were highest in Mexico (22.57) and Singapore (21.59). Excessive exercise was reported by 3.6% with no significant country differences. IPEDs use was reported by 28.3% of the sample, with the highest rates in Japan (60.6%). Logistic regression analyses revealed that PUI, excessive exercise and IPEDs use were significant predictors of appearance-related anxiety. Discussion and conclusions: The strong associations between PUI, excessive exercise, IPEDs use, and appearance anxiety underscore the complex interplay between online exposure, body image concerns and mental health. Cross-country differences suggest that socio-cultural factors influence appearance-related anxiety. These findings highlight the need for culturally sensitive interventions and policy measures that address the impact of digital media on body image, particularly to protect vulnerable populations.

Background and aims: Digitalisation and rapid technological advancements have intensified socio-cultural pressures surrounding body ideals and performance, contributing to the increased use of Image and Performance Enhancing Drugs (IPED). Body dissatisfaction, muscularity-oriented concerns, and distorted self-perception represent key drivers of this phenomenon and are further amplified by digital media, which increasingly promote IPED use. Although IPED use has been consistently associated with body image disturbances and eating-related psychopathology, its relationship with behavioural addictions remains largely underexplored. This represents a critical knowledge gap, given that IPEDs are often used to shape the body, regulate mood, sustain productivity, sharpen cognition, and intensify sexual experiences, all of which may contribute to compulsive patterns of behaviour. Methods: This narrative review synthesises existing literature examining IPED use in relation to behavioural addictions, including exercise addiction, eating disorders, work addiction, gaming disorder, gambling disorder, and compulsive sexual behaviour disorder. Results: Moving beyond traditional doping frameworks, it examines how IPED use is shaped by appearance-related disorders, compulsive behaviours, and social validation pressures. Particular attention is given to the role of digital environments and online fora in facilitating access to IPEDs, normalising their use, and interacting with reinforcement processes in these conditions. By integrating previously fragmented lines of research, the review proposes a novel framework that conceptualises IPED use as recurring across diverse behavioural addictions rather than an isolated phenomenon confined to sport. Discussion and conclusions: Understanding the mechanisms linking IPED use, behavioural addictions, and digital contexts is crucial for informing targeted public health strategies and the development of effective prevention and intervention approaches.