The Pro Ana phenomenon is developing fast and appears to be dangerous particularly with respect to the developmental age . Preliminary evidence shows that the age of onset of juvenile anorexia nervosa has decreased during the last decade . Steinhausen and Jensen report that in 1995 the peak age of onset was between 16 and 19 years, while in 2010 it ranged from 12 to 15 years . In our Center, in 2020, during the COVID-19 emergency, we received 89 patients aged 14 years or less compared to 47 with the same age range in 2019. Moreover, the effects of on-line harmful material on this population group seem to be more severe at both clinical and psychopathological levels . A systematic review of 7 studies carried out in 2010 showed an increase in caloric restriction, exercise and body dissatisfaction within disease duration and relative hospitalization in subjects with ED exposed to Pro Ana websites . A linguistic analysis of 129 college students carried out 10 years later showed that Pro Ana blog users have higher rates of negative emotions and related anxiety symptoms than control blog users . Likewise, a systematic review of 9 studies demonstrated an increase in body dissatisfaction and dietary restriction . The same authors carried out a qualitative analysis through an online survey to explore motivations and perceptions among the participants in an online community, and confirmed the role of the community in encouraging harmful weight loss and weight-control practices . Young people represent the highest number of Internet and social media users, with up to 89% of 18- to 29-year-olds using a social network site largely through their mobile phones. These trends underscore a greater need for further investigations into the relationship between social media use and eating disorder risk .
In 2009, the prevalence of viewership of Pro Ana websites was examined through the administration of a questionnaire in a sample of healthy adolescents in Belgium. This research explored whether any correlation existed between Pro Ana website visits and predictors of anorexia nervosa. It reported that 12.6% of the girls and 5.9% of the boys had visited such websites, and showed that in girls, visiting pro-anorexia websites was associated with a higher drive for thinness, worse perception of appearance and more perfectionism .
In current clinical practice the use of the Internet by patients with ED is not normally investigated. For this reason, we decided to conduct a cross-sectional study by anonymously surveying Italian patients affected by ED, who visited our clinical services in two different periods. In 2017, our population included both adults and adolescents, with a prevalence of the latter (64.7%) to investigate the general presence of such phenomenon. In 2020, we decided to focus only on a younger and specific age group (10–18 years) because the developmental age appears not only the most susceptible to the appeal of technology but also the most fragile from a clinical point of view. In fact, based on the prevalence of severe ED in developmental age in Italy identified by Gigantesco et al. in 2010, the rate of severe ED cases requiring hospitalization at the age of 10–19 is 22.8% .
Our research confirms the data reported in literature on how Web usage is today a fundamental part of the lives of our patients by showing that more than 80% of respondents use it daily. In our adolescent sample, we also observed increased awareness of the existence of Pro-Eating Disorders sites, increased knowledge and use of dietary sites, therapy-promoting sites and Pro Ana, and increased knowledge and use of specifically Pro Ana sites.
New technologies have changed the processes of personality development and consolidation, as well as the ways we relate to each other and the world. These profound changes correspond to changes in daily habits; the excessive use of virtual resources related to health also concerns the nutritional field. It is evident that patients with ED use the Web primarily to find information about food restrictions and losing weight, and for emotional support. Thus, they incur a series of health risks including those related to the Pro Ana phenomenon, which could induce or aggravate an ED in the subclinical phase .
Our research shows that patients with ED frequently visit food and nutrition/dietary sites (51.4% in 2017 vs 58% in 2020). This is a worrying practice if we consider how online resources are often inaccurate and provide incorrect and harmful health information. Patients who visit pro Ana sites often indicate that they visit pro-recovery websites as well: these data are important because they reflect a degree of confusion among young patients, who cannot discern the value, accuracy, harm and risks of the information they receive. For this reason, therapists should find new communication strategies to monitor their patients’ use of these online resources, whether to educate them to a critical use or to prevent them from using them at all.
A minority of the surveyed subjects, albeit growing (5.7% in 2017 vs 22% in 2020) acknowledged visiting and using Pro Ana websites; this is not surprising, as secrecy and concealment are reported as cornerstones of Pro Ana philosophy. Nevertheless, it is significant how the majority of patients (45.7% in 2017 vs 60% in 2020) said to be aware of the existence of Pro Ana practices, which suggests that they could become users of these sites if they are not already.
Considering the recent evolution of the means of transmission of Pro Ana material from blogs and personal forums to multimedia SNS, it is significant that in our findings in 2020 almost one half of the sample (49%) indicated they found Pro Ana material on such social media platforms as Instagram, Tumblr, and Facebook.
Finally, our patients stated that they had knowledge of other – non-Pro Ana – sites, which still promoted excessive thinness as an ideal of beauty (54.2% in 2017 vs 76% in 2020). This finding may be related to the bio-psycho-social etiopathogenetic model of anorexia nervosa, which postulates bio-socio-cultural factors at the origin of the disease. This model emphasizes the idealization of current aesthetic models conveyed by omnipresent messages on and offline.
Our research presents some limitations. It is a descriptive study designed solely for the purpose of describing the distribution of certain variables in the clinical population of interest. It does not address the association between these variables; for example, it does not establish a correlation between clinical subtypes of disease and the use of Pro Ana material. This, however, may be the topic of further research.
Our study investigates the presence of the Pro Ana phenomenon in Italy, and confirms the worrying increase in the knowledge and use of Pro Ana materials among young patients at developmental age.