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David Baxter PhD

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Continuous Monitoring Urged for Pro?Eating Disorder Websites
by Deborah Brauser, Medscape
June 23, 2010

Pro?eating disorder websites, which continue to present graphic images and content in an effort to encourage anorexia and bulimia behaviors, should be closely watched by clinicians, according to the first large-scale analysis of these sites.

"Continued monitoring will offer a valuable foundation to build a better understanding of the effects of these sites on their users," write lead study author Dina Borzekowski, EdD, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and colleagues.

Interestingly, over a third of the sites evaluated also included information on "prorecovery."

"Some [of these] 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 [67%]," investigative team member and senior study author Rebecka Peebles, MD, instructor in adolescent medicine at Stanford University School of Medicine in Mountain View, California, and with the Comprehensive Eating Disorders Program at Lucile Packard Children's Hospital, Palo Alto, California, said in a statement.

"Many people with disordered eating behaviors have days when they want to get better and days they have no interest in getting better. The websites reflect the individual characters of the people visiting them," she added.

"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," noted Dr. Peebles. "Right now, many patients are going to the web to express [their] feelings, instead of handling them through traditional models of care, such as psychotherapy."

The study is published in the June issue of the American Journal of Public Health.

A Snapshot of Available Content
Anorexia affects about 1% of young women and bulimia affects about 2%, with a smaller percentage of men affected by each, report the study authors.

"Adolescents exposed to pro?eating disorder websites have been shown to have higher levels of body dissatisfaction than [those] not exposed, as well as decreased quality of life and longer duration of eating disorders," they add.

Past studies that have conducted content analyses have examined fewer than a dozen sites at a time.

"We felt that it was important to get a snapshot at 1 point in time of what type of content was typical on these websites and to get a really broad perspective," Dr. Peebles told Medscape Psychiatry. "We found that about 91% of these websites were readily accessible to any child, adolescent, or adult who wanted to get on the Internet. And given that this content is just out there for anyone, it's important for [clinicians] to be aware of it."

Using specific pro?eating disorder search terms, the investigators found 180 active websites and evaluated all content, which often included interactive forums, calorie counters, themes (such as control, success, and perfection), "thinspiration" prose or images (such as photos of very thin models or celebrities), tips and techniques for weight loss, and recovery information.

Each site was then given a "perceived harm" score (from 1 to 5) based on how harmful the investigators deemed the site for users. A score of 4 to 5 was considered high, a score of 2 to 3 was medium, and a score of 1 was considered low.

Multiple Messages Given
The investigators found that 98% of the site administrators were female, 79% of the sites had interactive features, 85% displayed "thinspiration: materials, and 83% offered suggestions on how to engage in disordered eating behaviors. A total of 38% of the sites included recovery information or links.

In addition, "of the 60 sites that discussed eating disorders as a lifestyle choice or disease, 58% referred to it as a disease and 42% referred to it as a lifestyle choice," report the study authors.

"Although pro?eating disorder websites are often portrayed in a black-and-white manner, most of them exist on a continuum. This is likely the result of the mixed feelings eating disorder patients have about their disease," said Dr. Peebles.

Finally, 24% of the websites had high perceived harm scores (considered dangerous or very dangerous), whereas the rest of the sites studied received medium or low harm scores.

"To better understand how messages and potential harm are communicated through such media venues, researchers must continue to investigate both the messages an individual is exposed to and their impact," write the study authors.

Dr. Peebles noted that although clinicians may not want to discuss specific sites with their patients, they should at least talk about what types of images or messages are being encountered online.

"There's always that concern that you don't want to introduce these sites to young people if they haven't heard of them," she said. "But certainly you can start off a conversation by asking, 'Have you ever read about eating disorders online?' and 'What sorts of websites do you visit?' If that leads to a discussion about these sites, then that can be very helpful."

Dr. Peebles added that technology is always changing. "In addition to websites, people are now on Twitter or posting to YouTube. So it's important for clinicians to be vigilant and to know that this is a dynamic medium that keeps changing. There are a lot of ways of delivering distorted messages. We can't stop patients' use of the Internet, but we can be a voice of reason."

Good Data on Dangerous Sites
"I think it's good to have some back-up data to what we already know," Sondra Kronberg, MS, RD, CEDRD, founder and nutritional director at the Eating Disorder Treatment Collaborative in New York City and a spokesperson for the National Eating Disorders Association, told Medscape Psychiatry.

"We've seen all of this already in our offices, the panic that patients can have after just opening their Internet account and getting hit with the latest diet or photo," added Ms. Kronberg, who was not involved with this study. "So the images and claims from these [pro?eating disorder] websites are really very dangerous. I'm for any kind of scientific evidence that would support that and help us make more people aware of how dangerous this is."

When asked how clinicians should deal with patients who might argue that these websites also offer good information, Ms. Kronberg said that most patients will ignore the good and "attach" to the bad.

"These are vulnerable young people going to these sites and getting reinforcement for their obsessive, anxious, disordered thoughts. And that's what makes it really dangerous ? taking a disordered thought and putting it into action," she explained.

"The idea that constant exposure normalizes and minimizes a message isn't something that we don't already know, but I think there are good points that we can use to reinforce that with our clients," Ms. Kronberg concluded. "I tell my patients, just like with addicts, you can't go there. It's dangerous. It's toxic for you."

Source: Am J Public Health. Published online June 17, 2010.
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