In the past four decades, the Chinese dietary pattern has undergone significant changes, mainly characterized by higher intakes of fats, added caloric sweeteners, animal source foods as well as a higher reliance on processed foods (1–3). These changes have important consequences. First, increasing food consumption could improve the nutrition status of Chinese residents. According to estimates from the Food and Agriculture Organization of the United Nations (FAO), the prevalence of malnutrition in China has dropped from 24% in the 1990s to less than 10% (1). However, the overconsumption of high-calorie foods and processed foods is associated with increased rates of non-communicable diseases such as overweight, obesity, and diabetes. It is reported that more than half of Chinese residents are overweight or obese, with the overweight and obese rates being 34.3 and 16.4%, respectively (4). Compared to urban areas in China, rural areas have lower incomes, poor infrastructure, and often limited access to food and markets. As a result, overweight and obesity have become a major public health problem, but about 150.8 million people in China are still malnourished or micronutrient deficient (5, 6). Thus, it is important to understand the drivers of diet transition and nutrition outcomes.

Existing studies have mainly discussed the effects of income and urbanization on nutrient intake and health outcomes, while little attention has been paid to the role of Internet use. The literature finds that income elasticity of animal products (such as milk and its products, meat, and aquatic products) is high, while that of staple foods such as whole grains and starches is small or even negative (1). As a result, the diets of low-income people tend to be dominated by staple foods, which are the most cost-effective source of calories. As incomes rise, consumers increasingly focus on other attributes of food in addition to nutrition, such as appearance, taste, status value, odor, and degree of processing (7). Healthy foods generally cost more, and low-income people are more likely to settle for poor health choices in developed countries (8). Study also found that income affects health through five channels: nutritional intake, dietary diversity, dietary knowledge, food preferences, and eating out (6, 8). Urbanization may also affect nutritional transition and health. This is because people in cities are often closer to markets and have a wider choice of food (6). In addition, in the process of urbanization, individuals with different food cultural backgrounds influence each other (9). This interaction may lead to a shift in food preferences, so the nutritional transition also changes with the development of cities.

Internet use may also affect nutritional intake and health outcomes, but results are mixed and there is a lack of research on rural areas in developing countries. First, Internet use can improve food accessibility by allowing residents to access food that is not available in nearby supermarkets (10). Second, the Internet can reduce the transaction costs in the agricultural market and promote farmers’ market participation, thereby improving consumers’ affordability of food. More importantly, the Internet is the main channel for accessing food and nutrition information, and Internet use can further improve consumer dietary knowledge (11). These changes can further improve the dietary quality of rural residents. Based on the household survey data of 10,042 rural households in six provinces in China, Xue et al. (12) found that Internet use can increase calorie, protein and fat intake, thereby improving the nutritional status of rural residents. Shen et al. found that the dietary diversity of Internet users is higher than the respondents who do not use the Internet (10). The results of Ma and Jin’s (13) study showed that Internet use can significantly improve the dietary quality of rural residents in China. And one possible channel is that Internet use improves rural residents’ dietary knowledge, thereby optimizing their dietary structure. Cui et al. (14) found that Internet use increases dietary quality by cultivating consumers’ more positive attitudes toward diet. Similar results have been confirmed in other countries, such as Kenya and Australia (15, 16). These studies confirm that Internet use improves dietary quality in rural areas of China. Higher dietary quality means better nutritional health (17, 18). In addition, Internet can also serve as a way to promote healthy eating habits and increase physical activity interventions to reduce the risk of chronic diseases such as obesity and high blood pressure (19).

However, Internet use also have a negative impact on nutrition and health. Other studies have suggested that Internet use may increase the risk of overweight and obesity by increasing sedentary lifestyles and decreasing the amount of time spent outside (20). Internet addiction, especially among adolescents, can significantly affect eating behavior and nutritional health. Specifically, Internet-addictive users had higher rates of irregular bedtimes and smoking and alcohol abuse than non-addictive Internet users. In addition, among high-risk Internet users, irregular dietary behaviors due to loss of appetite, frequent skipping meals, and snacking may lead to unbalanced nutrient intake and health problems (21). Physical activity is considered to be an important way to maintain caloric balance and health. However, excessive use of Internet time may reduce the time spent on physical activity. According to the 51st China Internet Development Statistics Report, Chinese netizens spend an average of 3.8 h online every day. It should be noted that the majority of time spent online in rural China is spent watching videos and playing video games (22). Therefore, there may be a substitution effect between Internet use and physical activities. In other words, Internet use may reduce the physical activity of rural residents and therefore have negative effects on nutrition and health. The theoretical framework of how Internet use affects nutritional intake and health outcomes is shown in Figure 1. In the past decades, China’s Internet penetration has been on an upward trend, and by the end of 2016, the number of Internet users in China reached 731 million, ranking first in the world (13). According to the China Internet Network Information Center (CNNIC), there will be nearly 1.051 billion Internet users in China by 2022, and the Internet penetration rate will reach 74.4%. Figure 2 shows the trend of Internet development in China and the world. As shown in Figure 2, the number of Internet users in China is the first in the world, but compared with many European and American companies, there is still great room for development. Therefore, the effects of Internet use on nutritional intake and health outcomes may be long-lasting, and it is important to understand how Internet use affect nutritional intake and health outcomes in rural China.

The objective of the study is to better understand the effect of Internet use on nutritional intakes and health outcomes and shed light on its underlying channels. To this end, using CHNS panel data from 2004 to 2015, we employ regression models to quantify the effects and use instrument methods to solve the potential endogeneity problem.

This study contributes to the existing literature in the following three ways. First, unlike the previous studies focusing on the influences of urban residents’ Internet use on nutritional health, this study expands the content of existing studies in rural areas. Second, extant literature only focuses on the causal relationship between Internet use and nutritional health, without exploring the influencing mechanism. Therefore, the second contribution of this study is to provide a more detailed discussion of how Internet use may influence nutritional intake and health outcomes through two potential channels: diet quality and physical activity. Third, studies have extensively been done in developed world, while Internet use and nutritional health in most developing nations received few attentions. The results of this study not only have important reference value for the sustainable development of rural areas in China, but also have important reference value for the formulation of food policies and digital economy development systems in developing countries such as India, Vietnam and Thailand.

The reminders of this study as follows. The second part introduces CHNS data and methods of this study. The third part describes the empirical results. The fourth part compares the results with the literature and analyzes the limitations of this study. The last part is the conclusion.

In the past few decades, Internet penetration in China has risen rapidly. By the end of 2016, the number of Internet users in China had reached 731 million, placing the country first in the world, with an average annual growth rate of more than 40 million (6.2%) (38). The rapid development of the Internet has changed people’s food consumption patterns and living habits (39). These changes have further affected the population’s food consumption, nutritional outcomes, and health status. As shown in Figure 2, China’s Internet user is comparable to the world average level. And China is the largest developing country in the world, and findings such as the effects of Internet use on nutritional intake and health outcomes in its rural area may have some implications to other developing countries. While the Internet use is also growing rapidly in developing countries such as India, Vietnam, and Thailand, and the quality of diet is improving, nutritional health is an important issue for all developing countries. Therefore, the results of this study may have important reference significance for policymakers not only in China but also in other developing countries. In addition, although there are big differences between China and European and American countries in terms of economic and social development level, dietary structure, etc., the influence channels of Internet use on nutritional intake and health outcomes may be consistent. In this study, the influence channels of diet quality and physical activity have been verified, which can also be used as reference for the research on Internet use and nutrition and health in developed countries.

This study found that Internet use significantly improved dietary quality, such as HEI and DDS, which is consistent with the findings of existing literature. For example, Xue et al. (12). found that Internet access significantly increased protein intake, which could be conducive to improving dietary quality. Ma and Jin found that there is a positive relationship between Internet use and a healthy diet. Cui et al. (40) argued that Internet use can improve family dietary quality like the Chinese diet balance index (DBI). In rural China, the reasons why Internet use can improve dietary quality may be mainly due to the following two points. First, the Internet is one of the main ways to obtain nutrition and health knowledge, especially in rural areas. Therefore, Internet use can improve dietary quality by improving dietary knowledge. Second, the rise of online shopping can help rural residents buy food that is not available in nearby markets, improving food availability. Therefore, Internet use may have a significant positive impact on dietary quality.

Another important finding of this study is that Internet use increases the risk of overweight and obesity among rural Chinese residents. This finding is consistent with the findings of Corneel et al. (41). They believe that Internet use increases the likelihood of overweight and obesity among Australian students because it increases the amount of time spent watching TV and being sedentary. However, our results are contrary to those of Chen and Liu (42), who concluded that Internet access increases the income of urban residents and thus reduces their risk of being overweight. This difference may be due to systematic differences in income structure, living habits, and dietary intake between rural and urban residents. Previous studies also found that the relationship between income and nutrition outcomes is opposite in rural and urban China (43, 44). We also found that one of the important reasons is that Internet use increased the risk of overweight and obesity was to reduce the frequency of physical activity among respondents. One interesting finding is that for young adults and females, Internet use will not increase their risk of overweight and obesity. It is possible that younger, younger, and female groups are more concerned about weight management than male and older age groups. It is worth noting that current articles on Internet use in developing countries mostly focus on urban areas and mainly study the positive effects of Internet use on food consumption and nutritional intake. Therefore, our findings are an important supplement to the existing literature.

This study finds that there is a positive relationship between Internet use and the self-assessment score of health, which is consistent with the results of Luo et al. (45). Besides, Ding et al. (46) also argue that the Internet is beneficial to the mental health of Chinese older adults. However, Ma and Sheng (47) find that Internet use may reduce duration and parent-adolescent communication, thus hurting their mental health. Therefore, the impact of Internet use on different countries and groups may varied. At the same time, we also find that Internet use increases the likelihood of chronic disease. It can be explained as the same as overweight and obesity, that is because Internet use reduces physical activities. Considering that these three variables of overweight, obesity, and chronic are more objective than Health score, we argue that Internet use improves diet quality, whereas it reduces physical activity, Internet use has a negative impact on the health of rural residents. Therefore, Internet use has both positive and negative effects on the nutrition and health of Chinese rural residents.

There are some limitations in this study. First, due to data limitations, we only used hypertension and diabetes to measure chronic diseases. But follow-up studies could use other chronic conditions to measure health, such as anemia or hyperlipidemia. In the past two decades, some chronic diseases such as overweight and obesity have grown rapidly in China, rising rapidly from the long-term lower than the world level to the higher than the world level. Second, the data in this study is from 2004 to 2015, although this includes the 10 years with the fastest development of the Internet in China, it would be preferable if subsequent studies could use panel data from more recent years.

A series of studies have discussed the effect of Internet use on food consumption, but the impact of Internet use on nutritional outcomes and health is little known, especially in developing countries such as China. Using multiple years of CHNS data and regression analysis, this study finds that Internet use improved dietary quality, such as HEI and DDS among Chinese rural residents. However, Internet use may increase the risk of overweight, obesity and health problems in the study regions. One important reason is that Internet use reduces their physical activity. The study also finds that the impact of Internet use on overweight and obesity is not significant among women and young people.

Given that the rapid increase of number of the Internet users and the changing lifestyle (e.g., e-commerce) in Chinese rural area, it is suggested that policymakers may seriously take its negative effects into account when promoting the development of the Internet. For instance, enlarge the investment in the Internet infrastructure while assign more physical facilities to the rural communities. Providing more dietary knowledge and cultivate the awareness of the nutritional self-care to the male and the relative older people when using the Internet. Insights and experiences from the study may also be valuable for the nutritional well-being in those developing regions in the digital era.

Publicly available datasets were analyzed in this study. This data can be found at: http://www.cpc.unc.edu/projects/china.

ZD: Writing – original draft. JL: Writing – original draft, Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Software, Supervision, Validation, Writing – review & editing. YH: Conceptualization, Supervision, Validation, Writing – review & editing. WL: Validation, Writing – review & editing.