by Kristina Fiore

Websites that encourage teens to continue in their eating disorders tend to do so via “thinspiration” — a combination of images and prose that drive the viewer toward continued weight loss, researchers say.

About 85% of these sites provide thinspirational photos (or “thinspo”) of ultrathin women and oaths to “Ana” or “Mia” — nicknames for anorexia and bulimia — according to Dina L.G. Borzekowski, EdD, of Johns Hopkins, and colleagues.

Nearly 80% of the so-called pro-Ana or pro-Mia sites are also interactive and encourage users to post their own photos, artwork, and comments, they reported in the June 17 issue of the American Journal of Public Health.

“It’s a community,” Borzekowski said. “Some feel it’s an exclusive community of like-minded people who engage in similar behaviors.”

Some are even elitist. One site, for example, touts that an eating disorder “is a gift and you cannot decide to have an eating disorder. So if you are looking for a way to lose weight … move on, try Jenny Craig.”

Borzekowski suspects the sites have been around as long as the Internet itself, but to clarify the contents and the reasons patients use them, she and her colleagues reviewed 180 of them.

The vast majority — 91% — of the sites were open access and most were maintained by a single individual. Most offered pro-anorexia content (84%) but many also provided pro-bulimia content (63%). Rarely did the sites endorse only one eating disorder, the researchers said.

Although 85% provided “thinspiration,” 83% also offered overt suggestions on how to engage in eating disorder behaviors.

“The tips and techniques were suggestions and strategies to achieve rapid weight loss and even hide one’s eating disorder from concerned parents and friends,” Borzekowski said.

Although the majority of the sites did acknowledge that eating disorders are a disease, 42% called it a “lifestyle.” In fact, 16% of these sites had a written creed to “Ana” or a statement of the “Thin Commandements” — “Thou shall not eat without feeling guilty,” for instance.

“There are some [sites] that are quite blatant that they’re trying to promote eating disorders as a lifestyle,” said Rebecka Peebles, MD, of Stanford University in Palo Alto, Calif., who was also an author on the paper. “Those aren’t the most common, but they do occur for sure.”

Only 38% of the sites included recovery-oriented information or links, although the authors said they were surprised that this statistic was so high.

“It represents what’s out there,” Borzekowski said. “There are some people who suffer from this disorder, who realize it’s a disorder and want help, while there are others … who think it’s a lifestyle.”

Angela Celio Doyle, PhD, of the University of Chicago, who was not involved in the study, said that when she encounters patients who visit the sites, she tries to “find out what they’re learning, what kind of reactions they’re having.”

Since eating disorders disproportionately affect adolescents, she also works with families to try to curb visits to the sites by encouraging limits on screen time and use of parental controls.

“You can’t control everything an adolescent does, but at least you’re sending a message and eliminating the chances they have [of getting onto these sites],” she said.

But she cautioned that the more important factor may be keeping away high-risk individuals who haven’t progressed to a full-blown disease yet: “You don’t want them getting drawn down that path any more.”

The sites may also be valuable to the health professionals who treat patients with eating disorders by providing insight into the conditions.

“[The sites] do help you get into the psychology more — the isolation, the desperation, and the desire for support,” Celio Doyle said.

Peebles said that initially, the content was “pretty upsetting to me as a physician working to fight these illnesses.” But after she was able to watch the sites’ evolution, she noticed that they were “reflective of the different feelings that people with eating disorders are having.”

“Sometimes they want to get better, sometimes they don’t, and the sites often reflect that duality.”

Her concern now is that the sites potentially speak to an underserved portion of the population that is severely ill.

“We need more services for people with eating disorders,” she said. “We need to be able to identify who is struggling and help them in a [more helpful] way … so they don’t need to go online for these things.”

Kristina Fiore is a MedPage Today Staff Writer.

Originally published in MedPage Today. Visit MedPageToday.com for more eating disorder news.