Physicians who treat patients with anorexia or bulimia face a sinister obstacle in the form of Web sites that promote eating disorders as a lifestyle choice. These painfully thin patients, mostly young women, look to these sites for validation — and they get it, according to a California doctor who has studied their impact. "These Web sites are founded on the mistaken belief that eating disorders are not a disease, but a way of life," says Dr. Rebecka Peebles, a Stanford University adolescent medicine specialist. Peebles and Jenny Wilson, a Stanford medical student, presented their research on the subject at the annual meeting of the Pediatric Academic Societies in Washington, D.C., in May. What they found in their preliminary study, which they say is the first to examine the health effects of frequenting pro-eating disorder sites, is that these teens spend more time in the hospital and less time on their schoolwork than their peers who don't visit the sites. Peebles says there wasn't much difference when it came to length of their eating disorder, the number of their missed menses, presence or absence of osteoporosis, and their percentage of ideal body weight. Of the anorexics and bulimics studied, 40 percent said they had visited Web sites promoting eating disorders, while 34 percent said they had visited sites dedicated to recovery from the condition. About 50 percent of those studied hadn't visited either type of site. Peebles says that the overlap between those who had visited pro-disorder sites and those who had visited recovery sites was "surprising," but whether that's a positive or a negative is still up for interpretation. "Clearly, a lot of our patients are looking for information," she adds. Unfortunately, much of the information is not in their best interest. More than 60 percent of the study participants reported that they gleaned weight-loss and purging techniques from the pro-eating disorder Web sites, as well as ways to cheat during physician weigh-ins. What's dismaying, however, is that more than a third of those who visited recovery sites reporting learning weight-loss and purging techniques there as well. While Peebles says the mission of the recovery sites is "admirable," they are still a gathering place for anorexics and bulimics. "[Site organizers] can't control what's on their chat rooms and what messages get quickly posted on the bulletin board. And people can meet each other on these sites, and then go off and have independent conversations that the site has no control over either," she notes. Many of the so-called "pro-ana" (anorexia) and "pro-mia" (bulimia) sites promote extensive rations of water, diet soda and black coffee, as well as cigarette smoking as a hunger suppressant. One pro-ana site, www.plagueangel.net, says, "If you believe in the myth that something can rule over you without your consent, if you regard "ana" as a disease rather than a lifestyle or choice, and especially if you see yourself as the victim of an eating disorder, in need of recovery, seeking recovery, or having recovered, it is strongly suggested that you leave this site immediately. IF you choose to ignore this warning, you WILL be triggered by the content of this site and I will NOT be responsible for your decision to play with a loaded psychological gun. There are reasons why firearms are kept locked away from children. So grow a spine if you don't have a will, and get lost." The sites include "thinspiration" photographs of young women whose skeletal frames are clearly visible beneath their skin. One site hands out "Starving for Perfection" awards. Visitors to many of these sites are encouraged to buy solidarity T-shirts and jewelry with the "ana" and "mia" code words. Revenues help fund the sites. Peebles' study also looked at parental knowledge of pro-disorder sites. "Parents of pro-eating disorder Web site users were more likely to be concerned about information that their children got from the Web. They were more likely to know about the pro-eating disorder sites and to have discussed them with their children," she says. Yet, more than half the parents of recovery site users either didn't know about their child's Web surfing on the subject or were unaware of the information that could be gained from them. Peebles says in 2000 and 2001, the medical community put pressure on dominant Web search engines such as Google and Yahoo! to eliminate pro-ana and pro-mia sites from their search results. They complied and still try to comply, she says, but adds, "It is very easy on the Internet to get around such bans." Peebles describes an eating disorder as a "bio-psycho-social illness. We don't know exactly what the specific causes are, but we believe it is multi-factorial." Such influences include genetics, biology, emotions, family pressures and media images.