The first medical study of websites that promote anorexia as a lifestyle choice calls on Canadian health-care professionals and parents to educate themselves about the dangers of these sites.
The study, slated for publication in the August edition of The International Journal of Eating Disorders, said the websites are proliferating on the Internet. "Many of the websites promote a community of support for individuals with anorexia nervosa (AN). This information has the potential to increase both short-term and long-term medical risks associated with AN," wrote Mark Norris, a pediatrician at the Children's Hospital of Eastern Ontario and one of the four Canadian doctors who conducted the study.
Web users identify themselves as "pro-ana" (in favour of anorexia) or "pro-mia" (in favour of bulimia), meaning they view these eating disorders as lifestyle choices rather than diseases.
Three-quarters of the websites studied used religious language, such as the Ana Psalm or Creed, that focuses on control, starvation and self-hate. In some cases, "websites portrayed an almost cult-like feel. At one, followers were encouraged to make a pact with Ana and sign it in blood," the study states.
"These sites are dangerous because they encourage a sense of community among anorexics," Dr. Norris said in an interview. "There is a lack of awareness in the medical community about what the sites are comprised of, and how that can adversely affect patients. From my own experience, many family doctors don't really know what these sites are about."
Sites post images of waif-like women, such as model Kate Moss or actress Mary-Kate Olsen, whom they call "thinspos" as a way to provide "thinspiration" for others.
Weight-loss strategies, use of diet pills, laxatives and bowel-cleansing enemas or methods of hiding weight loss are common to the websites. Lyrics to songs such as Adam's Ribs by the band You Am I are often quoted:
As long as we don't eat, everything will be fine.
I just want to look fascinating, snorting the diet pills I'm grating
As long as we throw up, everything will be fine.
As long as we're emaciated, tastes outdated, yeah, everything will be fine.
Emily, 21, used to keep a pro-ana website as a way of reaching out to her friends who had eating disorders. Her entries included detailed lists of what she had eaten that day, and notes about her mood and sense of self-worth.
"This morning I weighed 110 lb," she wrote in one of her journal entries. "Half an apple, 2/3 of a cup of cereal, melba toast, granola bar, soymilk, spaghetti, and a rice cake with some peanut butter on it. Comes to a grand total of 1,263 calories." In response, friends would cheer her on to lose more weight.
Rather than posting "thinspiration" images, Emily posted slogans such as "Nothing tastes as good as thin feels" or "I want to be so thin so I can dance between raindrops, and so thin than I can walk on the snow and not leave a footprint." These were to motivate herself, rather than encourage others to copy her behaviour, she said.
Emily has given up her pro-ana lifestyle and now discourages others from pursuing this path.
"Being pro-ana gave me control over my life. I could celebrate little milestones like 'I only had so many calories today' or 'I only ate this much,' " Emily said from her home in Ottawa.
She said she does not believe her behaviour did others any harm. "I really doubt that I helped other people maintain that behaviour," she said. "I know I would have done what I've done even if there weren't websites out there encouraging people to have a pro-ana lifestyle."
Several therapists say these websites have made treatment of eating disorders more difficult.
An important part of battling the disease is the patient's acknowledgment that anorexia is an illness rather than a lifestyle choice, said Kali Munroe, a Toronto-based psychotherapist who specializes in eating disorders.
These websites encourage anorexics to do the opposite, she said.
"These websites make the disease more serious because they enhance the obsessive cycle," she said. "My clients learn things like which are the best weight-loss pills, how to vomit effectively and the best ways to reduce the appetite. Women go to these sites because they want to be supported in their quest, and that means they legitimize the disease."
Although these websites encourage anorexic behaviour, it is not yet known whether they are affecting the incidence of the disease nationwide, Dr. Norris said. Several clinics across Canada say they have seen a rise in the number of people seeking treatment for eating disorders.
At the Children's Hospital of Eastern Ontario, waiting times have increased considerably in the past year, Dr. Norris said.
Sheena's Place, a Toronto support centre for eating disorders, also said demand for its programs has risen in the past 12 months. The Calgary Health Region, which runs all the public eating-disorder programs in the Calgary area, also reported a rise in waiting times.
However, more research needs to be done to establish what connection, if any, these findings have to the websites, Dr. Norris said.
"These websites encourage behaviours that could cause serious medical harm. But it's difficult to determine how they affect the psychology of the users, because there hasn't been any research done to determine whether it's 20-year-olds or 12-year-olds looking at them."