The dangers and draw of online communication: pro-anorexia websites and their implications for users, practitioners, and researchers

#ForYou? the impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards

Videos glamourising disordered eating practices and body image concerns readily circulate on TikTok. Minimal empirical research has investigated the impact of TikTok content on body image and eating behaviour. The present study aimed to fill this gap in current research by examining the influence of pro-anorexia TikTok content on young women's body image and degree of internalisation of beauty standards, whilst also exploring the impact of daily time spent on TikTok and the development of disordered eating behaviours. An experimental and cross-sectional design was used to explore body image and internalisation of beauty standards in relation to pro-anorexia TikTok content. Time spent on TikTok was examined in relation to the risk of developing orthorexia nervosa. A sample of 273 female-identifying persons aged 18-28 years were exposed to either pro-anorexia or neutral TikTok content. Pre- and post-test measures of body image and internalisation of beauty standards were obtained. Participants were divided into four groups based on average daily time spent on TikTok. Women exposed to pro-anorexia content displayed the greatest decrease in body image satisfaction and an increase in internalisation of societal beauty standards. Women exposed to neutral content also reported a decrease in body image satisfaction. Participants categorised as high and extreme daily TikTok users reported greater average disordered eating behaviour on the EAT-26 than participants with low and moderate use, however this finding was not statistically significant in relation to orthorexic behaviours. This research has implications for the mental health of young female TikTok users, with exposure to pro-anorexia content having immediate consequences for internalisation and body image dissatisfaction, potentially increasing one's risk of developing disordered eating beliefs and behaviours.

Visions of recovery: a cross-diagnostic examination of eating disorder pro-recovery communities on TikTok

Individuals seeking support or inspiration for eating disorder recovery may turn to pro-recovery content on social media sites such as TikTok. While research has thus far treated pro-recovery social media as a fairly homogeneous space, many pro-recovery hashtags single out particular eating disorder diagnoses. This exploratory study used codebook thematic analysis of 241 popular pro-recovery videos on TikTok to compare the presentation of eating disorders and eating disorder recovery across five different diagnosis-specific hashtags: #anarecovery, #arfidrecovery, #bedrecovery, #miarecovery, and #orthorexiarecovery. These hashtags refer to the following eating disorder diagnoses respectively: anorexia nervosa, avoidant restrictive food intake disorder, binge eating disorder, bulimia nervosa, and orthorexia nervosa. Our analysis generated the following qualitative themes across the entire dataset: (1) centrality of food to eating disorders and recovery, (2) what eating disorders look and feel like, (3) recovery as a process, (4) getting and giving help, and (5) negotiating diet culture in recovery. To supplement our qualitative findings and facilitate cross-diagnostic comparisons, we also conducted one-way ANOVAs and chi-square tests to probe for statistically significant differences in audience engagement and code prevalence across the different hashtags. Our results indicate that there are clear differences in how recovery is envisioned on TikTok based on which diagnostic hashtags are employed. Such variations in how different eating disorders are imagined on popular social media demand further investigation and clinical consideration.

Bio-citizens online: A content analysis of pro-ana and weight loss blogs

Current neoliberal ideology in Western society encourages individuals to self-monitor their body to control population health. The resulting self-surveillance includes weight management, promoted as a marker of health. Disordered eating, like anorexia, is framed as a health disorder. However, weight loss is framed as a health initiative; we argue that these framings are engaging with the same body project, encouraging thinness as a marker of health and good bio-citizenry. Using content analysis to compare online blog context created by individuals engaged in weight loss and individuals who identify as pro-anorexia, we argue and evidence that both groups are engaged in body projects with shared parameters. Findings suggest each group is striving to embody a thin ideal through weight management. Specifically, weight loss bloggers and pro-ana bloggers demonstrate similar diet and exercise behaviours in online diaries detailing their weight loss experiences. Thus, weight loss and anorexia exist on the same spectrum of responsible bio-citizenry.

Public Health in the Information Age: Recognizing the Infosphere as a Social Determinant of Health

Since 2016, social media companies and news providers have come under pressure to tackle the spread of political mis- and disinformation (MDI) online. However, despite evidence that online health MDI (on the web, on social media, and within mobile apps) also has negative real-world effects, there has been a lack of comparable action by either online service providers or state-sponsored public health bodies. We argue that this is problematic and seek to answer three questions: why has so little been done to control the flow of, and exposure to, health MDI online; how might more robust action be justified; and what specific, newly justified actions are needed to curb the flow of, and exposure to, online health MDI? In answering these questions, we show that four ethical concerns-related to paternalism, autonomy, freedom of speech, and pluralism-are partly responsible for the lack of intervention. We then suggest that these concerns can be overcome by relying on four arguments: (1) education is necessary but insufficient to curb the circulation of health MDI, (2) there is precedent for state control of internet content in other domains, (3) network dynamics adversely affect the spread of accurate health information, and (4) justice is best served by protecting those susceptible to inaccurate health information. These arguments provide a strong case for classifying the quality of the infosphere as a social determinant of health, thus making its protection a public health responsibility. In addition, they offer a strong justification for working to overcome the ethical concerns associated with state-led intervention in the infosphere to protect public health.

Is it Important to Talk About Technologies with Eating Disorder Clients? The Health-Care Professional Perspective

Nowadays, the use of digital technology is an important issue that should be addressed during the treatment of people who have eating disorders. The involvement or absence of this issue reflects the understanding, experience, and atttude of health-care professionals toward their clients' use of technology. The aim of the present study was to investigate the perceptions of health-care professionals and their assessment of their clients' usage of digital technology while developing strategies for treatment. Semistructured interviews with 30 professionals were performed from October 2015 to June 2016 and a thematic analysis was used to analyze the data. The health-care professionals' views could be summarized in three thematic groups: (1) technology use is not relevant for the cooperation; (2) technology use is relevant for the cooperation and addressed generally; and (3) technology use is relevant for the cooperation and addressed specifically. The results are discussed in relation to the theoretical model presented by Rodgers about the impact of technology on disordered eating behaviors and the implications for practice.

A content analysis of an online pro-eating disorder community on Reddit

Pro-eating disorder communities provide a refuge for individuals with eating disorders (EDs) who are ambivalent about seeking treatment. We investigated a pro-ED community on Reddit, an anonymous social networking platform with topical forums, to identify expression of behaviors aligned with ED symptoms and support for these behaviors. A content analysis on four weeks of topic-specific discussion threads (N=125 comments, 115 replies to comments) was conducted to identify behaviors consistent with ED psychopathology and support for these behaviors (informational, tangible assistance, esteem/emotional support). Results indicated that the content aligned with expressions of clinically relevant ED psychopathology, with eating concerns (49/125) and shape concerns (47/125) being most prevalent. The majority (92/115) of replies provided esteem/emotional support to the comment author. Online interventions and/or recovery programs are needed to counteract reinforcing dialogue that occurs on social media sites, like Reddit, and promote ED recovery through supportive messages on these platforms.

Inducing Behavioral Change in Seekers of Pro-Anorexia Content Using Internet Advertisements: Randomized Controlled Trial

BACKGROUND

The influence of pro-anorexia (pro-ana) websites is debated, with studies indicating both negative and positive effects, as well as significant variation in the effects of different websites for those suffering from eating disorders (EDs) and the general population. Online advertising, known to induce behavioral change both online and in the physical world, has not been used so far to modify the search behavior of people seeking pro-ana content.

OBJECTIVE

The objective of this randomized controlled trial (RCT) was to examine if online advertisements (ads) can change online search behaviors of users who are looking for online pro-ana content.

METHODS

Using the Bing Ads system, we conducted an RCT to randomly expose the searchers for pro-ana content to 10 different ads referring people to one of the three websites: the National Eating Disorders Association, the National Institutes of Mental Health, and MyProAna. MyProAna is a pro-ana website that was found in a previous study to be associated with less pathological online behaviors than other pro-ana websites. We followed participants exposed and unexposed to the ads to explore their past and future online searches. The ads were shown 25,554 times and clicked on 217 times.

RESULTS

Exposure to the ads was associated with a decrease in searches for pro-ana and self-harm content. Reductions were greatest among those referred to MyProAna (reduction of 34.0% [73/215] and 37.2% [80/215] for pro-ana and self-harm, respectively) compared with users who were referred elsewhere (reduction of 15.47% [410/2650] and 3.21% [85/2650], respectively), and with users who were not shown the ads, who increased their behaviors (increase of 57.12% [6462/11,314] and 4.07% [461/11,314], respectively). In addition, those referred to MyProAna increased their search for treatment, as did control users, who did so to a lesser extent. However, users referred elsewhere decreased their searches for this content.

CONCLUSIONS

We found that referring users interested in ED-related content to specific pro-ana communities might lessen their maladaptive online search behavior. This suggests that those who are preoccupied with EDs can be redirected to less pathological online searches through appropriate pathways.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03439553; https://clinicaltrials.gov/show/NCT03439553 (Archived by WebCite at http://www.webcitation.org/6xNYnxYlw).

Young people, self-harm and internet forums

A generation of digital natives are living their lives in fundamentally different ways from previous generations. The rapid advance of the internet and mobile telephones, and the adoption of online social media, mean that substantial parts of the social lives of young people are played out in online settings. This has implications for how young people discuss and seek help for mental health problems. This commentary discusses the role of online forums for young people who self-harm. Practitioners need to understand the potential harms and benefits, and explore how benefits can be harnessed and harms minimised.

A thematic content analysis of #cheatmeal images on social media: Characterizing an emerging dietary trend

Despite the pervasive social endorsement of "cheat meals" within pro-muscularity online communities, there is an absence of empirical work examining this dietary phenomenon. The present study aimed to characterize cheat meals, and explore the meaning ascribed to engagement in this practice. Thematic content analysis was employed to code the photographic and textual elements of a sample (n = 600) that was extracted from over 1.6 million images marked with the #cheatmeal tag on the social networking site, Instagram. Analysis of the volume and type of food revealed the presence of very large quantities (54.5%) of calorie-dense foods (71.3%) that was rated to qualify as an objective binge episode. Photographic content of people commonly portrayed highly-muscular bodies (60.7%) in the act of intentional body exposure (40.0%). Meanwhile, textual content exemplified the idealization of overconsumption, a strict commitment to fitness, and a reward-based framework around diet and fitness. Collectively, these findings position cheat meals as goal-oriented dietary practices in the pursuit of physique-ideals, thus underscoring the potential clinical repercussions of this socially-endorsed dietary phenomenon.

Recovery Amid Pro-Anorexia: Analysis of Recovery in Social Media

Online communities can promote illness recovery and improve well-being in the cases of many kinds of illnesses. However, for challenging mental health condition like anorexia, social media harbor both recovery communities as well as those that encourage dangerous behaviors. The effectiveness of such platforms in promoting recovery despite housing both communities is underexplored. Our work begins to fill this gap by developing a statistical framework using survival analysis and situating our results within the cognitive behavioral theory of anorexia. This model identifies content and participation measures that predict the likelihood of recovery. From our dataset of over 68M posts and 10K users that self-identify with anorexia, we find that recovery on Tumblr is protracted - only half of the population is estimated to exhibit signs of recovery after four years. We discuss the effectiveness of social media in improving well-being around anorexia, a unique health challenge, and emergent questions from this line of work.

What's eating the internet? Content and perceived harm of pro-eating disorder websites

The internet is a popular tool for information dissemination and community building, serving many purposes from social networking to support seeking. However, there may be a downside to using some online support communities. For individuals with eating disorders (EDs), it is possible that certain online communities may reinforce the negative social aspects that encourage these disorders, rather than positive aspects that would facilitate treatment and recovery. Previous research identified several linguistic themes present on pro-eating disorder websites in an attempt to better understand the web-based conversation in the pro-eating disorder movement. We hypothesized that differences in theme presentation may predict changes in perceived harm. The present study sought to understand the perceived harm, and presentation patterns of pro-eating disorder (Pro-ED) website content. We replicated and extended previous research by having laypersons code these websites' content using previously identified linguistic themes and rate perceived harm. Our data replicate and extend the previous research by finding the same associations between co-occurring themes, and investigating associated perceived harm. We found that themes of Sacrifice, Control, Deceit, and Solidarity were associated with the highest perceived harm scores. In addition, we suggest an initial conceptualization of the "Eating Disorder Lifestyle", and its associations with the themes of Isolation, Success, and Solidarity. This research may provide clinicians with information to better understand the potential influence these sites have on eating disorders.

The changing face(book) of psychiatry: can we justify 'following' patients' social media activity?

Individuals with mental health issues may post information on social networking sites that can provide an insight into their mental health status. It could be argued that doctors (and specifically psychiatrists) should understand the way in which social media is used by their patients to gain a better insight into their illnesses. However, choosing to actively monitor a patient's social media activity raises important questions about the way in which medical students, qualified clinicians and other healthcare professionals obtain information about patients. While this may be framed as a mere form of 'collateral history-taking', there are obvious practical and ethical problems with doing so. Here, a case is made against monitoring the social media activity of patients involved with psychiatric services.

Online Stigma Resistance in the Pro-Ana Community

Media scholars often use concepts from Goffman's dramaturgical approach to study online communities of stigmatized individuals as "backstages," spaces where members take refuge from social disapproval. In this study, I extend this view through an examination of in-depth interviews with bloggers from the "pro-ana" community, an online community for people with eating disorders. To explore how this community uses an online environment that is both anonymous and public, I fuse Goffman's ideas about identity performance and stigma with more recent theories about boundary maintenance. In-depth interviews with "pro-ana" bloggers reveal that to protect this virtual group and resist stigmas associated both with their illness and with their online presence, they construct their own norms and rules in the online realm, and discipline and eject members deemed to be out-group.

The use of pro-ana blogs for online social support

The aim of this research was to document the content on pro-ana blogs and to uncover how the unique socio-technical features of blogs (interactivity, self-disclosure, masspersonal communication) facilitate social support among members. A final sample of 48 pro-ana blogs provided 624 individual units for coding. Results indicate that prevalent forms of social support were emotional support, esteem support, and informational support. A new category, reciprocal self-disclosure, was also revealed to be quite frequent. Blogs are spaces where social support is sought and communicated among members of the pro-ana network. Interpretation of blog communication and implications for treatment and research are discussed.

Healthy habits or damaging diets: an exploratory study of a food blogging community

This exploratory study describes the virtual socialization, behaviors, and attitudes being promoted in one community of food bloggers. Two months of entries from 45 blogs created by young women belonging to a photography-based food blogging community were analyzed and coded using a qualitative approach. Analysis revealed widespread group practices as well as the promotion of attitudes and behaviors associated with dietary restraint. The present study highlights the need for further research using food-blogging communities, and concludes with a cautionary note about blogs as sources of health information in view of the consequences of dietary restraint.

Cultura Identitária pró-anorexia: características de um estilo de vida em uma comunidade virtual

Anorexia nervosa é uma doença inscrita na "Classificação Internacional de Doenças". Entretanto, jovens pró-anoréxicas acreditam que estejam adotando um "estilo de vida". O objetivo deste artigo é analisar a "cultura identitária" dessas jovens, investigando uma comunidade virtual brasileira. Metodologicamente, foi utilizada a Etnografia Virtual em três "núcleos de sentido" identificados na comunidade: a tensão entre anorexia como doença versus estilo de vida; as versões sobre ideal de perfeição e o significado do pertencimento ao grupo. Os resultados encontrados sugerem que a identidade pró-anorexia diverge do modelo biomédico. Ela admite que o corpo magro serve como referência de reconhecimento social e sucesso econômico. Neste sentido, os fóruns online permitem uma construção da identidade pautada no anonimato. Conclui-se que estudos sobre práticas anoréxicas em comunidades virtuais devem ser estimulados, pois contribuem para a compreensão do universo juvenil e colaboram com a promoção de políticas e ações voltadas para a saúde do adolescente.

Prospectively predicting dietary restraint: the role of interpersonal self-efficacy, weight/shape self-efficacy, and interpersonal stress

OBJECTIVE

This study investigated how the precursors of interpersonal self-efficacy and weight/shape self-efficacy would interact in the face of interpersonal stress to prospectively predict dietary restraint. Three models were explored, each with a different type of interpersonal stress: stress from same sex friendships, opposite sex friendships, or romantic relationships.

METHOD

At Time 1 (T1), participants (N = 406) reported on their typical levels of interpersonal self-efficacy and weight/shape self-efficacy, and recent (past 28 days) dietary restraint. At Time 2 (T2), 11 weeks after T1, participants reported on their recent (past 28 days) levels of dietary restraint at that time. Between T1 and T2, participants completed inventories weekly on the previous week's interpersonal stressors.

RESULTS

Consistent with prediction, low interpersonal self-efficacy and high weight/shape self-efficacy combined with high interpersonal stress (whether from same sex friendships, opposite sex friendships, or romantic relationships) to predict the highest levels of T2 dietary restraint after controlling for T1 levels.

DISCUSSION

These results further link the interpersonal domain with dietary restraint and elucidate characteristics of women particularly apt to increase dietary restraint in response to interpersonal stress.

e-Ana and e-Mia: A content analysis of pro-eating disorder Web sites

OBJECTIVES

The Internet offers Web sites that describe, endorse, and support eating disorders. We examined the features of pro-eating disorder Web sites and the messages to which users may be exposed.

METHODS

We conducted a systematic content analysis of 180 active Web sites, noting site logistics, site accessories, "thinspiration" material (images and prose intended to inspire weight loss), tips and tricks, recovery, themes, and perceived harm.

RESULTS

Practically all (91%) of the Web sites were open to the public, and most (79%) had interactive features. A large majority (84%) offered pro-anorexia content, and 64% provided pro-bulimia content. Few sites focused on eating disorders as a lifestyle choice. Thinspiration material appeared on 85% of the sites, and 83% provided overt suggestions on how to engage in eating-disordered behaviors. Thirty-eight percent of the sites included recovery-oriented information or links. Common themes were success, control, perfection, and solidarity.

CONCLUSIONS

Pro-eating disorder Web sites present graphic material to encourage, support, and motivate site users to continue their efforts with anorexia and bulimia. Continued monitoring will offer a valuable foundation to build a better understanding of the effects of these sites on their users.

Interpersonal interactions on online forums addressing eating concerns

OBJECTIVE

Although some research suggests that online eating disorder forums promote "pro-eating-disorder" lifestyles and discourage recovery, other research suggests that such forums are an important source of interpersonal support. The current study extends this research by exploring the positive and negative behaviors encouraged on these forums and by comparing forum members' perceptions of support received from online and offline relationships to support received in relationships of age-matched controls.

METHOD

In a survey of 60 forum members, we assessed information exchanged and support provided on eating disorder forums. Further, we assessed perceptions of social support for general and specific life concerns in this group of forum members as well as 64 age-matched university controls.

RESULTS

Results show that both adaptive and maladaptive behaviors are encouraged on the forums, and that this encouragement has some influence on forum members trying out these behaviors. Overall, forum members reported receiving less support for their eating concerns as compared to their general life stressors, and they perceived less support for both their general concerns and eating concerns in their offline relationships as compared to their online forum relationships. Moreover, forum members reported receiving less support from their offline relationships as compared to support received in relationships by age-matched controls.

DISCUSSION

Forum members perceive less support in their important relationships than other peers do, and they seek out and participate in forums as a means of attaining greater social support. However, our research suggests that these forums also encourage dysregulated eating behaviors. Implications of online forum support and its impact on recovery are discussed further.

Eating disorders blogs: testing the quality of information on the internet

The objective of this study is to describe content quality and its relation with authorship and/or affiliation in eating disorders blogs. The results reveal that indication of authorship in the 391 blogs studied implied greater suitability of the contents concerning eating disorders, as did the existence of affiliation to an institution. In conclusion, indication of authorship in association with a reputed institution should be recognised as representing the primary quality criteria to be borne in mind.

Pro-anorexia websites: what a clinician should know

OBJECTIVE

The purpose of this study was to conduct a content analysis of the "Tips and Tricks" section of pro-ana websites to better understand information shared on these sites, and aide clinicians in identification, treatment, and prevention of anorexia.

METHOD

Nine pro-ana websites were evaluated to identify categories of information in "Tips and Tricks." A content analysis was performed using emergent coding methods and 16 categories were determined. Reliability was acceptable (Cohen's Kappa = 0.702). Discrepancies were corrected by consensus. Frequencies of individual categories were computed.

RESULTS

Most "Tips and Tricks" are directed at dieting/restricting calories (28.6%) and distraction (14.0%). Most disturbing, 11% of comments were directed at lying and concealing symptoms.

DISCUSSION

Clinicians aware of "Tips and Tricks" might be better equipped to recognize the symptoms of anorexia early in treatment. Knowledge of "Tips and Tricks" can also facilitate better education, making it difficult for clients to conceal their illness.

Refining the relationships of perfectionism, self-efficacy, and stress to dieting and binge eating: Examining the appearance, interpersonal, and academic domains

OBJECTIVE

This study investigated domain-specific (appearance, interpersonal, and academic) interactive relationships of perfectionism, self-efficacy, and stress to dieting and binge eating, positing that the level of weight/shape self-efficacy would be pivotal in identifying elevated dieting versus elevated binge eating.

METHOD

Participants were 406 randomly selected undergraduate women. At two time points (T1 and T2), 11 weeks apart, participants completed measures of dieting and binge eating attitudes/behaviors as well as domain-specific measures of perfectionism and self-efficacy (e.g., perfectionism related to appearance). Between T1 and T2, participants completed inventories weekly on the previous week's weight/shape, interpersonal, and academic stressors.

RESULTS

The combination of high interpersonal perfectionism, low interpersonal self-efficacy, high interpersonal stress, and high weight/shape self-efficacy was associated with the most elevated dieting. The hypothesized interactions related to the appearance and academic domains where not supported.

CONCLUSION

These results highlight the interpersonal context for dieting and the unique relationship between weight/shape self-efficacy and dieting.

What does viewing a pro-anorexia website do? An experimental examination of website exposure and moderating effects

OBJECTIVE

This study experimentally examined the effects of viewing a pro-anorexia website.

METHOD

Following construction of a prototypic pro-anorexia website, 235 female undergraduates were randomly assigned to view either the pro-anorexia website or one of two comparison websites related to female fashion (using average-sized models) or home décor. Post-website affect, cognitions, and behavioral expectations were examined along with moderator effects.

RESULTS

Study participants exposed to the pro-anorexia website had greater negative affect, lower social self-esteem, and lower appearance self-efficacy post-website than those who viewed a comparison website. Additionally, they perceived themselves as heavier, reported a greater likelihood of exercising and thinking about their weight in the near future, and engaged in more image comparison. Minimal support was found for moderator effects.

CONCLUSION

Results provide an empirical basis for concern (expressed by clinicians, researchers, the media) that pro-anorexia websites are a troubling new form of thin-ideal exposure that warrants further examination.

Inside the "pro-ana" community: a covert online participant observation

A covert participant observation was conducted into the meanings of interaction in the "pro-ana" online community. Specifically, the researchers were interested in the kind of psychological support offered by such websites and by the beliefs of community members towards eating disorders and the processes of treatment and recovery. One of the authors joined a number of pro-ana sites in the guise of a plausible persona and experienced a variety of responses from community members, some extremely hostile, others very supportive, yet without ever being exposed as an interloper. These starkly different responses challenge the notion of a broad "pro-ana" philosophy, suggesting that the sites are best understood as local cliques offering temporary relief from offline hostility, but it is doubtful whether they can be said to possess any therapeutic value beyond the immediate online context.