1. 110 www.thelancet.com Vol 379 January 14, 2012
World Report
For more on H&M’s virtual
models see http://newsfeed.
time.com/2011/12/07/hm-
admits-to-using-computer-
generated-bodies-for-models/
For more on Beating Eating
Disorders see http://www.b-eat.
co.uk
For more on tips and tricks see
Int J Eat Disord 2009;
DOI:10.1002/eat.20396
For more on awareness of
pro-ana sites see Pediatrics 2006;
DOI:10.1542/peds.2006-1133
For more on the position paper
see http://www.rcpsych.ac.uk/
docs/Pro-ANa%202ndof%20
June2009[2].doc
For more on Proud2Bme see
http://proud2bme.org/home
Peer through the window of any
western high street fashion retailer and
your eyes will be caught by images of
very thin models. The fashion industry
andmediahavefacedmuchcriticismfor
perpetuating a distorted idea of beauty.
Most recently the clothing retailer H&M
was lambasted for using computer
generated models to advertise their
clothing. “The prevailing aesthetic of
extreme thinness is certainly part of the
cultural influence to which some people
are particularly vulnerable”, observes
Susan Ringwood, chief executive of
UK charity Beating Eating Disorders.
People with anorexia nervosa are
particularly vulnerable to this type of
media influence. Pro-anorexia (pro-
ana) websites, which draw on the thin
ideal generated by the media, have
materialised across the web to promote
and adviseon anorexia in recentyears.
“Pro-ana websites are online com-
munities of individuals who believe
that anorexia is not a serious psychiatric
condition that requires treatment, but
rather it’s a lifestyle choice”, says Helen
Sharpe from the Section of Eating
Disorders, Institute of Psychiatry,
London, UK. “So typically what you see
on these websites are tips and tricks on
how to lose weight, how to hide that
weight loss from others, and what’s
calledthinspiration.”
This so-called thinspiration consists
of photographs of emaciated models,
who supposedly provide inspiration
for weight loss. The tips and tricks are
particularly shocking (eg, “purge in the
shower! It covers up the sound, smell,
and washes out the evidence”). The
contentofthesesitesposesapotentially
serious health risk. “About a third of
patients with eating disorders have
used these websites. When it comes to
the dangers ofthese sites,there aretwo
big things that we need to think about:
one is that these sites might induce an
eating disorder [in vulnerable people]
or maybe if you already have an eating
disorder, these sites make it difficult
to recover”, warns Sharpe. “We know
that people with anorexia are often
terrified of being made to give up their
anorexia, and are therefore reluctant
or at least ambivalent about recovery
or accepting help. Pro-ana sites exploit
this ambivalence”, adds Ulrike Schmidt
head of the eating disorders section
at South London and Maudsley NHS
FoundationTrust, London,UK.
Censorship of pro-ana sites might
seem to be the most logical step,
but many barriers to this approach
exist. “There is no internationally
enforceable legislation that could be
effective in this area. The internet is
a global phenomenon, and much of
its operation is beyond the scope of
legislators. User generated content—
young people running pro-ana sites
from their own bedrooms—cannot
easily be legislated against, as there is
no corporate entity or legal owner. We
are not sure what purpose it would
serve to make people affected by a
serious mental illness criminals too”,
says Ringwood.
Although many young people with
eating disorders are aware of pro-
ana websites, their parents and many
healthprofessionals,mightbeunaware.
“Health professionals working in eating
disorders will be aware of pro-ana sites
and ofthe associatedtips andtricks and
howtodealwiththem,butotherhealth
professionalslikelytocomeintocontact
withpatientswitheatingdisorderssuch
as GPs [general practitioners], nurses,
dietitians, and other doctors I suspect
are less aware of these issues”, suggests
Schmidt. Since censorship is impractical
and could marginalise people with
anorexia, educating the public about
the dangers of these sites is the
most effective alternative. However,
traditional methods for raising public
awareness, such as media campaigns,
could have counter productive effects
by drawing attention to these sites.
In a 2009 position paper on pro-ana
websites, the UK’s Royal College of
Psychiatrists called on the media “not
to make pro-anawebsites into headline
news, not to report their content in a
sensationalised way and not to report
how to access them, as this may lead to
increaseduseof such sites”.
Meanwhile, the UK’s Body
Confidence Campaign has pledged
to improve the media’s knowledge
about eating disorders and the
National Eating Disorders Association
has launched Proud2Bme, an online
community that provides support and
advice, while promoting a positive
body image and encouraging healthy
attitudes about food and weight.
Although these efforts will help
reduce the number of people visiting
pro-ana sites, they will not completely
solvetheproblem.Peoplewithanorexia
areattractedtothesesitesbecausethey
provide a virtual refuge where they can
freely express themselves, without fear
of judgment. “We believe the answer
lies in providing that same sense of
acceptance and support throughout
society, so that a pro-ana site is no
longer the only refuge a person feels
they can seek. We would therefore not
try to promote awareness of the pro-
anorexia sites, but rather promote
compassionate understanding of
eating disorders in general”, concludes
Ringwood.
MarioChristodoulou
Pro-anorexia websites pose public health challenge
In recentyears,websitesthat promote anorexia and advise people on howto maintainthe disorder
have appeared ontheweb. MarioChristodoulou examinesthe health risks of such sites.
“‘About a third of patients with
eating disorders have used
these websites...’”
NickDolding/GettyImages