Pro or con? Anorexia nervosa and the internet

Background: Adolescents increasingly use the Internet as a primary source for health information. Web sites related to anorexia nervosa (AN) are providing a venue for dispensing information on nutrition, techniques to lose or gain weight, motivation, and links to other related sites. Purpose: To describe information found in three different types of web sites associated with AN: pro-anorexia ("pro-ana" advocating AN), pro-recovery and professional organizations. Methods: Web sites were initially identified by a public search engine and then "links" on these sites yielded approximately 500 pro-ana sites, 100 pro-recovery sites and 30 professional sites. Of this total, 100 pro-ana, 50 pro-recovery and 20 professional sites were randomly selected for analysis of content including: (1) Biography of the site designer or organization's mission, (2) Number of visits to site, (3) Weight control techniques and, medical information, (4) Nutrition advice and information, (5) Avoiding detection, (6) "Support groups" for eating strategies, (7) "Motivational" images, quotes and literature advocating the sites philosophy, (8) Links to other web sites, (9) References to mortality from AN. Results: Pro-ana sites provided specific instructions for initiating and maintaining AN (generally in the third person). Technique and nutrition sections prescribed habits and practices for rapid weight loss. Clinical definitions of AN were detailed to aid in evading detection by clinicians. Motivational images, "creeds and commandments" encouraged continued weight loss. "Support groups" fostered competitions for weight loss. Content analysis: 64% contained a biography (average age 16.7 years), 60% counted visits (mean 34,998, plus or minus 116,293, range 164 to 94,869 visits), medical/weight advice-58%, nutrition content 91%, methods to avoid detection 75%, support groups 49%, motivation content 94% (84% images and 81% writing), links to other sites 87%, mortality associated with AN 5%. Pro-recovery sites overwhelmingly presented introspective first person viewpoints on AN and had little nutritional advice. Content analysis: biography 94%, site visits 50% (mean 27,878, plus or minus 38,949 visits, range 640 to 94,869 visits), medical/weight advice 69%, nutrition content 25%, support groups 25%, motivation content 92% (25% images and 87% writing), links 56%, mortality associated with AN 38%. Professional sites contained more clinical information about AN, and less nutritional content or