First large-scale analysis of pro-eating disorder websites

The study, the first large-scale analysis of pro-eating disorder Web sites, points out the complex emotions that eating-disorder patients grapple with and gives valuable insights into the variety of material they encounter online as they seek support from their peers.

"These sites are fairly diverse," said Rebecka Peebles, MD, senior author of the new study, which will appear June 17 in the American Journal of Public Health. "Some sites have very hard-core information about how to intensify your eating disorder, some have a lot of pro-recovery content and many have a mix of both." Peebles is an instructor in pediatrics at Stanford and an adolescent medicine specialist with the Comprehensive Eating Disorders Program at Lucile Packard Children's Hospital.

Anorexia and bulimia affect about 1 and 2 percent of young women, respectively, as well as smaller numbers of males. Anorexia patients maintain a very low body weight and fear weight gain despite being dangerously thin. Bulimia patients repeatedly binge on large quantities of food, then "purge" calories by vomiting, abusing laxatives or diuretics, or over-exercising. Both diseases can cause serious long-term health problems, and severe cases may lead to death.

The paper reports on 180 Web sites that were found using search terms such as "Pro-Ana," "Pro-Anorexia," "Pro-Bulimia" and "Thin and Support." The researchers evaluated each site's basic logistics; accessories such as interactive forums or calorie counters; themes (including control, success and perfection); "thinspiration" images, tips and techniques for weight loss; and recovery information. They assigned each site a "perceived harm" score based on their assessment of how harmful the site would be to users.

Nearly 80 percent of the sites had interactive features, 85 percent displayed "thinspiration" materials (such as photos of very thin models or celebrities) and 83 percent offered suggestions on how to engage in disordered eating behaviors. Yet most sites recognized that eating disorders are a disease, and more than a third included recovery information. Twenty-four percent of the Web sites had high perceived-harm scores (4 or 5 on a scale of 1 to 5); the rest of the sites received medium or low harm scores.

"Although pro-eating-disorder Web sites are often portrayed in a black-and-white manner, most of them exist on a continuum," Peebles said. That is likely the result of the mixed feelings eating-disorder patients have about their disease, she added: "Many people with disordered eating behaviors have days when they want to get better, and days they have no interest in getting better. The Web sites reflect the individual characters of the people visiting them."

Clinicians who treat eating disorders and family members of eating-disorder patients need to be aware that the sites exist, are easy to access and can help reinforce disordered eating patterns, Peebles concluded.

"If these sites make us uncomfortable, the focus at the public health level should be asking how we can reach and treat more people struggling with disordered eating, and how we as providers can become more comfortable with the difficult feelings that people with eating disorders feel," she said. "Right now, many patients are going to the Web to express those feelings, instead of handling them through traditional models of care, such as psychotherapy."

Other authors include the lead author, Dina Borzekowski, from John Hopkins School of Public Health, and Jenny Wilson, MD, a pediatric resident at Lucile Packard Children's Hospital.