For three years, when Alison Devenny wanted weight loss tips, she turned to the Internet. But she didn't look for typical dieting Web sites. The George Washington University sophomore visited Web sites that encourage visitors to embrace anorexia and bulimia as "lifestyle choices" and provide instruction on how to do so.
The sites provide "thinspirational" pictures of extremely underweight women, menu suggestions, discussion boards and tips on topics including ways to overcome hunger pangs, such as doing household chores and drinking lemon water.
Despite attempts to encourage Internet service providers to close down such sites, many continue to exist. A recent Google search using the term "pro-anorexia" yielded 30,000-plus results. Many were links to pages by health authorities warning about the pro-anorexia movement, while others were links to sites no longer in operation. But many linked to live sites. A Google directory called "Pro-Anorexia" links to more than 50 sites.
Carol Day, director of health education services at Georgetown University and a member of the school's eating disorder treatment team, called the sites "dangerous and disturbing."
Experts say the sites can reinforce unhealthy behaviors, slow the recovery process and discourage people from seeking help.
"I think anyone who is working in the field of eating disorders realizes how unhealthy" the sites are, Day said.
"I always kind of knew that what I was doing was stupid," said Devenny, now 19, who has since begun treatment for multiple eating disorders. She used to visit the sites about twice a week, she said, picking up tips on how to avoid eating and how to keep her illness a secret from her family.
The terms "Ana" and "Mia" -- short for anorexia (a condition characterized by eating so little that one's health and life are at risk) and bulimia (overeating and then purging by vomiting or taking laxatives) -- are often used by those with eating disorders who don't want treatment.
Frequent visitors to these sites refer to themselves as "anas" and "mias" and say the sites offer a safe haven where they can talk, share advice and commiserate away from the harsh criticism of family, friends and other "outsiders."
The sites' creators are typically teenagers and young adults who have eating disorders. Many are directed at women, who experience eating disorders more often than men.
About 0.5 to 3.7 percent of women suffer from anorexia in their lifetimes, according to the National Institute of Mental Health (NIMH). About 1 to 4 percent are bulimic. NIMH estimates that about 2 to 5 percent of Americans experience binge eating disorder (characterized by excessive eating that occurs, on average, at least two days a week in a six-month period).
Those with eating disorders exhibit serious disturbances in eating behavior and feelings of extreme concern about body shape or weight, the NIMH says. Researchers are investigating how voluntary behaviors, such as eating different sizes of food portions, at some point develop into an eating disorder. Experts agree that eating disorders are not due to a failure of will but are treatable medical illnesses.
Eating disorders are often accompanied by depression, substance abuse and anxiety disorders. Common personality characteristics include excessive anxiety, perfectionism and low self esteem. Treatments include hospitalization or outpatient treatment, as well as psychotherapy, nutritional counseling, cognitive therapy, behavioral therapy and antidepressant medication, according to the Harvard Eating Disorders Center.
About half of people with anorexia or bulimia recover completely through treatment, according to the Harvard center. About 30 percent make a partial recovery, and 20 percent have no substantial improvement. The mortality rate for anorexia is about 5.6 percent per decade, according to NIMH. Cardiac arrest and suicide are common causes of death for anorexics. But "Anas" and "Mias" say they are not sick, don't need to be "fixed" and don't want sympathy. They develop creeds and post poetry and online diaries reciting their beliefs. They applaud one other for reaching low weights. Their message board conversations often turn to statistics: height, weight, measurements.
A site called Blue Dragon Fly sells red bracelets to encourage "solidarity" among pro-anas. "So you can go out into the world and not have to wonder, 'Is she or isn't she?' . . . You see the red bracelet, and you know," the site explains.
But it's the pro-eating disorder advice that many women say they seek on these sites. There are tips for the best foods to eat and vomit up later ("remember if it is hard to swallow it will be hard to 'unswallow,'" one site says) and how to cover up your eating disorder (tell friends and family you're sick or have already eaten, tips another site). A college sophomore from Alexandria diagnosed with bulimia and anorexia said tips from pro-eating disorder sites helped her go from 161 pounds to her current 74 pounds.
"At times I did gain back the weight, but I would always make a plea for help on the pro-ana" Web sites, she wrote in an e-mail responding to a reporter's question. She asked not to be identified by name, adding that although her family knows she has an eating disorder, they don't know -- and wouldn't approve of -- her visiting these sites. She called the sites "a tether to bring me back on track when I start to think about going into rehab or bingeing without purging."
Some Internet service providers shut the sites down in 2001 after the nonprofit National Eating Disorders Association (NEDA) and other groups complained that the sites contained content that could harm minors. Many sites disappeared briefly, only to reemerge later under different names and on different Internet domains.
Seattle-based NEDA has since changed strategies, opting to create increased awareness and education about eating disorders on the Web and elsewhere.
"There's the whole free speech issue" in trying to have sites removed from the Web, said NEDA chief executive officer Lynn Grefe. Unless sites encourage or reflect specific crimes, most Internet service providers have been reluctant to shut them down.
America Online, which has about 23 million U.S. subscribers, has removed several pro-eating disorder Web sites in the past few years under its policy prohibiting "material that defames, abuses, threatens, promotes or instigates physical harm or death to others, or oneself," according to company spokesman Andrew Weinstein. "Encouraging an eating disorder would fall into the category of promoting physical harm to others," Weinstein wrote in an e-mail.
Grefe said NEDA realized that its time was better spent getting the word out about eating disorders and treatments, rather than pushing to eliminate the sites. "We can't rid the world of these sites . . . but we can be more proactive in trying to get real information out to the public," Grefe said.
NEDA sets up booths at schools to educate students about eating disorders and available treatments, and it runs a confidential telephone help line. It also offers eating disorder information on its Web site.
Health professionals said people who think they may have eating disorders should seek medical treatment, rather than surf the Web for advice.
"I would prefer that individuals not access that particular door [pro-eating disorder sites] because I think there are dangers involved," said David B. Herzog, president of the Harvard Eating Disorders Center.
Most sites offer a disclaimer on their home pages: "If you are currently in recovery from an eating disorder or if you are offended or otherwise disturbed by the existence of pro-ana, I suggest you go no further," warns a site called The Thin Files. Others discourage visits by those under 18.
The Blue Dragon Fly site takes a different approach. It acknowledges that eating disorders are mental illnesses. Still, discussions on its forums resemble those on other sites. But its creator warns on the home page: "Tips are to give you fresh ideas on how to stay on track so that you don't fall into a depression and kill yourself -- not to teach you how to 'not eat.'"
Some site visitors are harshly critical of former anas and mias who have sought treatment. The creator of a site called Help Me Ana explains on her home page that she has gotten treatment and will no longer be maintaining the site. Some visitors signed her site's guest book and wished her well, but others accused her of turning against them.
"HAH recovery, u r jus like the rest of them, u tune in & cop out wen it gets tough, i hope ur happy wen u get fat & hideous. Ana loved u & ur rejecting her 2 join the obesians," read a message signed by someone using the screen name "witchyfingers."
"I feel kind of bad for girls who go into it with a little less maturity and buy into everything they read," said Devenny, an international studies major from New Jersey who is now in therapy and on medication for anorexia, bulimia and binge-eating disorder.
"I think it's dangerous, especially in the wrong hands. . . . This is a life and death matter for a lot of people."
To reach the National Eating Disorders Association's confidential help line, call 800-931-2237. For more information about eating disorders and treatments, visit http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=337, www.hedc.org or www.nimh.nih.gov/publicat/eatingdisorders.cfm.