Eat Weight Disord (2013) 18:413–420
DOI 10.1007/s40519-013-0050-y
ORIGINAL ARTICLE
A comparative analysis of anorexia nervosa groups on Facebook
Martin Teufel • Eva Hofer • Florian Junne •
Helene Sauer • Stephan Zipfel • Katrin Elisabeth Giel
Received: 15 March 2013 / Accepted: 18 July 2013 / Published online: 27 July 2013
 Springer International Publishing Switzerland 2013
Abstract
Purpose To analyze the content and culture of anorexia
nervosa (AN)-related communication on the current major
social network site (SNS) Facebook.
Methods We searched for groups and sites related to AN
on Facebook by means of a faux profile of a young female.
Identified groups/sites were analyzed with respect to (1)
category (education, self-help, professional help, pro-ana,
anti pro-ana), (2) activity, (3) motivational aspects (prose,
pictures), and (4) social support.
Results Numerous relevant groups were found in all
categories except that professional help was almost non-
existent. Pro-ana groups were found to be the most active,
best organized, and offered the highest levels of social
support. Prose motivation was distinctly offered in all
categories. Motivation with pictures was particularly evi-
dent in pro-ana groups. The most functional motivation
was found in self-help groups.
Conclusions SNS appears to be a relevant way for young
females suffering from AN to communicate and exchange
disease and health-related ideas. Caregivers, researchers,
and institutions in the field of eating disorders should be
aware of the existence, possibilities, dysfunctions, and
influence of SNS. Whether SNS can help persons with AN
to get therapeutic assistance as well as whether it can be
integrated into psychotherapeutic strategies should be
examined in future studies.
M. Teufel
E. Hofer (&)
F. Junne
H. Sauer
S. Zipfel

K. E. Giel
Department of Psychosomatic Medicine and Psychotherapy,
University Hospital Tübingen, Osianderstrasse 5,
72076 Tübingen, Germany
e-mail: eva-maria.hofer@med.uni-tuebingen.de
Keywords Eating disorders
Anorexia nervosa

Motivation
Social support
Social media
Introduction
The role of the Internet as a mass media has significantly
grown over the last decade. Information seeking is
becoming more and more important via the Internet. With
the development of Web 2.0, the Internet has emerged as a
tool that is increasingly and often predominantly used for
communication, via social media applications such as
Facebook, Myspace, or Twitter [1, 2].
With respect to Internet use, patients with eating disor-
ders express their wish for professional, evidence-based
online information and expert-guided treatment [3].
Research on Internet-based treatment approaches is grow-
ing and results are promising [4]. On the other hand, a large
pro-eating disorder community has developed on the
Internet with the purpose of promoting anorexia nervosa
not as an illness, but as a lifestyle choice. Norris et al.
(2006) characterizes the typical content of such pro-ana
webpages as follows. One section describes the founders of
the page and their medical history considering the eating
disorder. Eventually, a disclaimer that this is a pro-ana
homepage can be found. There are sections that encourage
unhealthy eating behaviors through text (referred to as
‘‘Tips and Tricks’’), images, or videos (‘‘Thinspiration’’).
Additionally, one might find a forum where users can talk
to each other [5].
Over the past decade, the pro-ana movements have been
scientifically analyzed, concerning their structure [6–8],
their way of communication [2], and the harm they
potentially cause to ill as well as to healthy individuals.
Visiting pro-eating disorder webpages was associated with
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a higher drive for thinness and higher levels of perfec-
tionism [9]. Harper (2008) [10] as well as Bardone-Cone
and Cass et al. (2007) [11] showed that viewing a pro-
eating disorder webpage was associated with more nega-
tive effects, negative body image, and less social self-
esteem in healthy individuals. Also, a reduction of the
actual calorie intake of healthy individuals and individuals
with AN after viewing a pro-eating disorder webpage could
be shown [12, 13]. The majority of scientific publications
on the issue underline these potentially harmful effects of
pro-ana webpages. However, there are also authors who
argue that those webpages could be a way of social support
for socially stigmatized patients [14, 15] and that the pro-
ana forums could be a form of supplement for support that
cannot be obtained from off-line relationships [16]. Fur-
thermore, clinicians should be informed about pro-ana
webpages. Being aware of ‘‘Tips and Tricks’’ that patients
are promoting and using might help in being better
equipped to recognize the symptoms of anorexia early in
treatment [17].
As the importance of the Internet is growing, the
importance of social network sites (SNSs) is expanding as
well. SNSs are considered an increasingly important
medium for communication and to get in touch with peers
and interest groups [1, 2]. Their importance is growing
through the increasing number of members and concomi-
tant commercialization with financial benefits. The biggest
SNS temporally is Facebook with over 901 million
monthly active users [18].
Facebook contains public or semi-public profiles within
a bounded system, where users can share information with
other users with whom they share a certain form of con-
nection, referred to as a ‘‘friendship’’ [1]. On profiles one
can present oneself via profile pictures, interests, or on a
‘‘wall’’. The ‘‘wall’’ of one’s profile is a place where one’s
own ideas and thoughts can be made public and where
friends can leave ‘‘posts’’. The content of posts can be
messages, ideas, thoughts, or media-like pictures or videos.
Studies show that the way an individual presents oneself on
an SNS seems to reflect the actual personality traits the user
has [19]. Furthermore, it is possible to create special
‘‘groups’’ with other users who share a common interest.
Those groups can be modified in their privacy settings
within a range from public to private, where only registered
group members can see the content and communication of
the group. Posts can be made on walls of groups/sites as
well. Other users can comment or ‘‘like’’ posts of other
users. Posts, likes, and comments are used as a communi-
cation tool on Facebook [18].
Juarascio et al. (2010) [20] analyzed the two large SNSs,
Myspace and Facebook regarding the existence of pro-ana
groups within them. They found a wide range of pro-eating
disorder groups/sites and stated that the majority of them
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Eat Weight Disord (2013) 18:413–420
were geared toward providing social support. Ringwood
(2008) [21] already described the mediation of social
support by pro-ana groups on social networking sites and
highlighted the necessity of providing an alternative for
users.
This is to our knowledge the first study that compre-
hensively analyses the culture of AN-oriented communi-
cation on the current major SNS Facebook in detail. We
searched not only for pro-ana groups, but also for groups
that aim to provide education, self-help, or professional
help for people suffering from AN. The primary aim of the
study was a detailed description and comparative analysis
of anorexia nervosa-related groups/sites. Furthermore, as
an exploratory approach we sought to describe differences
in social support and motivational aspects.
Methods
Faux profile
To identify and observe groups concerning AN, a faux
Facebook profile of a young female was created. The faux
profile aimed to mimic typical AN-specific member char-
acteristics. To fit into the pro-ana setting and for being
accepted there, the profile had to be adapted concerning
name, profile picture, and basic information according to
observed pro-ana. For example, the name was changed to
the pseudonym ‘‘Jana T-Spo’’. Names that included terms
like ‘‘Ana’’, ‘‘Thinspo/T-Spo’’, ‘‘Princess’’, etc., could be
observed throughout the pro-ana community on Facebook.
Likewise, the picture was modified to be a portrait picture
of a popular, emaciated white model, with BMI of about
14 kg/m2, aged about 16 years. This was a profile that
could be observed throughout the community as well. We
defined that the faux profile was accepting friendship
requests, but not making any requests. Accepting was
important for getting access to more hidden pro-ana
groups. The profile joined groups and sites, but never
posted or commented on them. With the approach of
observing passively, we intended to avoid influencing
group/site members or reinforce AN in members as much
as possible. This procedure was developed together with
the local ethics committee of the medical faculty.
Search process
Informed by previous research [6, 20] and experiences
collected throughout the Facebook search, our search
included the following terms: anorexia; bulimia; eating
disorder; ABC Diet; MiAna; AnaMia; thinspiration;
thinsperation; thinspo; pro-ana; pro-mia; stop pro-ana; stop
thinspo; and anti pro-ana. The Facebook search mask has
Eat Weight Disord (2013) 18:413–420
certain limitations concerning the reproducibility of the
results. Facebook search results depend on personal con-
text, social context, the query, and global popularity. Those
factors tend to change when accepting new friend request
or joining groups, etc. So, the results a query might get in
the first place will not be the same as when the search takes
place at a later point of time or through another individual
[22]. We screened the first 90 results that each term
delivered (corresponding to the first two pages of search
results). Further analyses were performed on those groups/
sites that met the following inclusion criteria: content AN
(character of the groups/sites needed to be no tweet, no
event, etc.); accessibility; group-size ([2 members); and
language (German, English, French, Italian, or Spanish).
Categories
The results were then coded into five primary categories
(education, anti pro-ana, self-help, professional help, pro-
ana). The aim of education groups/sites was to provide
objective education about the topic of eating-disordered
and anorectic behavior. Their first goal was not to offer
self-help, but to inform people unaware of AN. Anti pro-
ana groups/sites were considered for educational purposes
as well, but as a direct reaction to pro-ana. Their principal
purpose was to create awareness of the existence of pro-ana
groups and their unfavorable influence on vulnerable
individuals. Self-help groups/sites were established by
individuals affected by AN or relatives of affected indi-
viduals. Their main purpose was to give not only infor-
mation, but also to offer help such as advice or support to
other affected individuals. Professional help groups/sites
were conducted by larger groups with a higher level of
internal organization such as institutions or even hospitals.
Pro-ana groups/sites were bound to support the opinion
that AN is a lifestyle choice rather than a disease, similar to
pro-ana webpages on the World Wide Web [5–7].
Site logistics
Group/site size was defined as the number of users who
stated themselves to be members of a group or liked a site.
The visual representation of the group/site through a pic-
ture (usually given by the founder) reflects identity and
self-perception [23]. Pictures were split into food, body, or
other content. The activity of groups/sites was assessed
by evaluating the time since the last post made by a user
(B1 day,\3 days ago,[3 days ago,[1 week ago,[1 month
ago, [3 months ago, or no activity at all). The number of
spam posts was counted. The contents of spam posts were
primarily offers of diet pills, sexual contact, and dubious
health promotion.
415
Motivational aspects
Motivational aspects were assessed by categorizing
‘‘posts’’ (statements group/site users can make on the wall
of a group/site). Motivation with words reflects posts that
contain quotes, summons, reassurances, etc. [‘‘you could
be the model type, skinny with no apetite…’’, ‘‘The only
difference between FAT and EAT is one line’’, ‘‘Real
women have curves and aren’t afraid to show them’’, ‘‘just
take care and stay strong…this (whatever it is that you are
going through) too shall pass…let this be your mantra’’]
on groups/sites. Motivation with pictures reflects posts
with motivational pictures or videos of motivational con-
tent on the groups/sites, e.g., skinny models, skinny body
parts (especially hip bones, thighs, collarbones, the gap
between the legs), skinny celebrities, or on the other hand
pictures that intend to motivate a more recovery-oriented
behavior (videos with pictures of landscapes or flowers,
music videos, pictures of tattoos or drawings of symbols
with special meanings, or pictures of dangerously emaci-
ated women).
Social support
Social interaction played a central role in SNS and was
assessed by counting the number of comments/likes to a
post. We took the quantity of comments/likes as a bench-
mark of visible reactions that followed a post. Due to the
primary descriptive character of the study, we did not
distinguish between positive and negative comments.
Given that these social interactions via comments/likes on
SNS are comparable to a sort of social support, we defined
and calculated a new variable, reflecting the amount of
comments/likes per post and thus the extent of social
support. Social support was measured to tips and tricks to
overcome or maintain AN (e.g., exercise, food, weight), as
well as to AN-specific emotionally relevant themes (e.g.,
experiences with AN, reasons for AN, significance of AN,
attitudes toward therapy).
Statistical analysis
According to the aim of the study, analysis was primarily
descriptive. Only for exploratory issues significant differ-
ences concerning motivation and social support were cal-
culated. Because the data were not normally distributed,
the Kruskal–Wallis test was applied to compare groups.
Significance level was set at the a = 0.05 level. Profes-
sional help was not included in further analysis due to not
being statistically representative. We used SPSS 19 for
Mac OS X in conducting the analysis.
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416 Eat Weight Disord (2013) 18:413–420

Results Site logistics

118 groups/sites met the inclusion criteria (Fig. 1). 22.2 %
of the pro-ana groups/sites that took part in the analysis
were not received via Facebook search, but by being
invited for ‘friendship’ via the faux profile.
The number of groups within one of the previously
defined five main categories differed substantially.
Especially, the section concerning professional help was
found to be only marginally represented (four groups/
sites of 114). Because of the small number of groups/
sites in this section, professional help was excluded
and 114 groups/sites could be included in further
analysis.
Our search revealed a larger number of groups at 83.9 %
(n = 99) when compared with sites at 16.1 % (n = 19).
Concerning language, we found a large quantity of
English-speaking groups/sites with 70.3 % (n = 83), fol-
lowed by 11.0 % German-speaking groups/sites with
(n = 13), 8.5 % Spanish-speaking groups/sites (n = 10),
6.8 % Italian-speaking groups/sites with (n = 8) and 3.4 %
French-speaking groups/sites with (n = 4).
Group/site size showed the following distributions:
education had a mean group/site size of 469.7 (median
108), self-help 1,327.2 (median 144), anti pro-ana 297.0
(median 140.5), and pro-ana 883.3 (median 66).

Fig. 1 Search process and

groups/sites included in analysis Facebook search revealed
3524 results

118 groups/sites 3406 groups/sites

met inclusion did not meet
criteria inclusion criteria

Education Not in the top 90

29 groups/sites per search item
2473 groups/sites

Anti pro-ana
34 groups/sites Group/Site size too
small
35 groups/sites
Self-help
24 groups/sites

No regular
Professional help groups/sites
4 groups/sites 304 groups/sites

Pro-ana
Content not AN
27 groups/sites
399 groups/sites

Languages other
than ger, eng, fre,
ita, spa
81 groups/sites

Access denied
21 groups/sites

Others
93 groups/sites

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Eat Weight Disord (2013) 18:413–420 417

The representation of the group/site through the group

picture is shown in Table 1. Education, anti pro-ana, and
pro-ana showed a more body-associated sampling of group/
site pictures, while self-help chose more pictures of other
content than body or food.
The activity of a group/site was assessed by the last
post users made on the wall (Table 2). Pro-ana was found
to be most active with 33.3 % showing the last post within
the last 24 h. On the other hand, about half of the edu-
cation and anti pro-ana groups showed low activity levels
with the last post made more than 3 months ago. The
amount of spam found on the groups/sites showed pro-ana
(1.23 % spam posts) and self-help (1.56 %), well-kept in
comparison to education (7.11 %) and anti pro-ana
(4.33 %).

Motivation

Motivation with words exists in all categories with self-

help revealing most prose motivation (Fig. 2a). We found
no significant differences among the categories in this
respect (p = 0.09). As seen in Fig. 2b, motivation with
pictures was predominantly represented in pro-ana
(p = 0.05). Motivational pictures in education, self-help,
and anti pro-ana describe being underweight as negative,
whereas pro-ana describe it as positive.
Fig. 2 a Motivational quotes/sentences as found on the group/sites
(frequencies). b Motivational pictures as found on the group/sites
Social support (frequencies)

Social support to tips and tricks (comments/likes per post) themes (comments/likes per post) was similar in all cate-
predominantly occurred in pro-ana with 6.67 per post and gories (p = 0.60; see Fig. 3b).
differed significantly from the other categories (p = 0.02;
see Fig. 3a). Social support to eating disorder-specific
Discussion
Table 1 The representation of the group/site via the group picture
Food Body No picture Other This is to our knowledge the first study to investigate the
associated associated % (n) % (n) role of SNS related to AN analyzing Facebook content, as
% (n) % (n) this is currently the largest SNS. Since previous research
Education 3.4 (1) 51.7 (15) 20.7 (6) 24.1 (7) focused predominantly on dysfunctional pro-ana activity
Self-help 4.2 (1) 33.3 (8) 4.2 (1) 58.3 (14) [5–7, 14, 20], we also included recovery-oriented groups
Anti pro-ana 2.9 (1) 55.9 (19) 11.8 (4) 29.4 (10)
(education, self-help, anti pro-ana).
Pro-ana 3.7 (1) 70.4 (19) 18.5 (5) 7.4 (2)
AN-specific groups were found to be numerous in the
SNS Facebook with self-help groups having the highest

Table 2 The last activity (time passed since last post) of a group/site
B24 h % (n) \3 days % (n) [3 days % (n) [1 week % (n) [1 month % (n) [3 month % (n) No activity % (n)

Education 0 (0) 3.4 (1) 3.4 (1) 27.6 (8) 10.3 (3) 44.8 (13) 10.3 (3)
Self-help 12.5 (3) 12.5 (3) 0 (0) 12.5 (3) 20.8 (5) 37.5 (9) 4.2 (1)
Anti pro-ana 8.8 (3) 2.9 (1) 0 (0) 17.6 (6) 17.6 (6) 52.9 (18) 0 (0)
Pro-ana 33.3 (9) 14.8 (4) 11.1 (3) 7.4 (2) 11.1 (3) 18.5 (5) 3.7 (1)

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Fig. 3 a Social support concerning tips and tricks (comments/likes
per post). b Social support concerning eating disorder-associated
themes (comments/likes per post)
number of members. On the whole, pro-ana groups were
found to be the most active ones. They predominantly
identify themselves with body-associated pictures, whereas
self-help groups use pictures apart from AN-relevant
objects (food or body). For motivational aspects, pictures
are very important in pro-ana groups. All categories
motivate users with words. Social support was similar in all
categories concerning emotional AN-specific themes.
Social support concerning tips and tricks (e.g., ‘‘Crunch on
some ice chips if you are feeling a hunger craving. This
will help you feel as if you are eating something sub-
stantial.’’ ‘‘How do you all feel about laxatives?’’) was
most pronounced in pro-ana groups.
Since pro-ana has developed throughout the Internet into
a strong and highly active movement, its existence on a
popular SNS such as Facebook was expected. The nature of
pro-ana as being harmful to individuals on the one hand
and giving a certain amount of support to their users on the
other hand has been extensively debated before [5, 7, 8, 10,
14]. However, there is another important aspect that should
be taken into consideration: How is pro-ana and its social
support positioned in comparison to other groups dealing
with the topic of AN?
Our aim was not only to show the perspective of the
dysfunctional behavior related to the illness, but also to
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Eat Weight Disord (2013) 18:413–420
find out in what form resources for recovery are available
on Facebook as a major SNS and how they present them-
selves in comparison to pro-ana. SNSs with their high
amount of given structures for their group/sites grant for
the first time the opportunity to draw a direct comparison
between pro-ana and self-help and education groups with
regard to AN.
The trend of pro-ana webpages being well organized and
maintained [6, 7, 20] could be observed on Facebook as
well. While the last activity of recovery-oriented groups
was on average later than a week ago, pro-ana had its
highest amount of activity on a daily basis to extend to
3 days. Also, the amount of spam found on the groups/sites
showed pro-ana well kept in comparison to education and
anti pro-ana. These impressions suggest that pro-ana
groups/sites have a higher interest of keeping their groups
organized and neat. This could be going along with per-
fectionism as a relevant personality trait in a non-recovered
stadium of AN [24].
Both education and anti pro-ana groups often gave the
impression that they were founded to make a statement
against AN-related behavior or against AN itself, unlike
self-help and pro-ana groups/sites, which seemed to be
established to serve as a real forum for support and help.
Concerning the way support and help was presented and
offered, pro-ana and self-help groups varied in certain
points. While chosen pictures representing the self-under-
standing of pro-ana as well as education and anti pro-ana
groups were mainly body-associated, self-help groups
displayed pictures that were neither body nor food asso-
ciated. This suggests different motivational stages of
change in the different groups [25]. The aim of self-help
seems to be a communication without potential AN-trig-
gering cues. Given that the group/site picture is one of the
first to be seen by approaching groups, education and anti
pro-ana, which tend to have body-associated pictures,
possibly aim for a different target group than self-help. The
target groups of education and anti pro-ana seem to be
users interested in pro-ana or users at the beginning of an
eating disorder with the aim of giving information or to
scare. The target group of self-help are users or their next
of kin who are in at least partial recovery from AN.
Motivation with pictures is most common in pro-ana
groups/sites with body-related pictures being most fre-
quently used (e.g., skinny models). This aspect is similar to
the type of group picture for self-representation described
above in pro-ana groups. This finding is in accordance with
experimental research (e.g., using functional magnetic
resonance imaging (fMRI) to assess brain activity and eye
tracking to assess gaze patterns) demonstrating that
patients with AN show marked differences in the pro-
cessing and evaluation of body-related pictures as com-
pared to healthy subjects [26, 27]. AN patients tended to be
Eat Weight Disord (2013) 18:413–420
more attentive to body parts indicative of weight status
(e.g., thighs), were more interested in pictures of under-
weight bodies, and perceived them as more rewarding.
These processing patterns might be correlates of body
dissatisfaction and a pronounced thin ideal and might
contribute to the maintenance of the disorder. Hence, the
confrontation with body-related pictures on Facebook
profiles might again elicit such processing and rewarding
patterns [28] and contribute to maintenance of symptoms
and behaviors related to the eating disorder.
All categories used motivational techniques with words
for their health belief models. Categories with less activity
showed also lower motivational aspects. Motivation in anti
pro-ana groups were often through posts like ‘‘Close all
pro-ana groups’’ without the implication of a welcome
response. The overall character of these groups is centered
around the goal to get pro-ana groups/sites shut down
without giving help on how to battle AN. Education had
few posts with motivational content in words or in pictures
reflecting the aim of giving information and not assistance.
Education and anti pro-ana had few comments/likes per
post (social support) concerning relevant AN themes (1.07
and 1.87). Pro-ana had with 3.9 comments/likes per post
the highest social support followed by self-help with 2.41.
This finding reinforces the idea that pro-ana provides its
members a platform in the distant cyberspace that enables
to perceive a certain amount of social support without
being at risk of being valuated, criticized, or confronted
with the limitations of real life [29]. However, future
studies should address social support in more detail (e.g.,
positive/negative valence of reactions to posts). Concern-
ing the care and motivation given in those groups, it is
obvious that Facebook offers a sanctuary for the pro-ana
community. On the other hand, the faux profile was cleared
and inactivated by Facebook about half a year after being
adapted to pro-ana profiles. This shows that Facebook
works with an intrinsic control. However, we have not been
able to get information from Facebook about criteria and
procedures for shutting down an account.
An important result of the study is that pro-recovery
activity on Facebook was found. However, the relevant
groups seemed to be less attractive to users than pro-
anorexia oriented groups (presentation, activity, motiva-
tional purposes). There seems a lot to be done to reach the
aim that recovery-oriented groups/sites get an equivalent or
superior alternative to the pro-ana shelter. Although
patients with AN report the wish for valid health-related
information [3], we found only a very limited number of
professional help groups. The reasons for the lack of pro-
fessional help groups are complex. Probably, a general
unawareness of the potentialities of SNS in therapeutic
contexts exists. The possibilities for individual design
on Facebook are limited. However, information about
419
institutions could easily be provided (e.g., addresses, hot-
lines, and external website pages). Our findings underline
the possibility of integrating SNS into treatment networks
[4]. The role model for the design and structure of pro-
fessional help groups could be existing Internet platforms,
e.g., ProYouth an EU-Initiative [30] which gives ideas how
interactive online contact can be provided.
Several limitations occurred during our research: Given
the fact that Facebook is a constantly changing medium,
the reproducibility of the results was limited. A number of
groups/sites could not be included into the analysis because
of the restrictions of access. Due to limited access, an
underestimation of the existence of pro-ana groups might
be possible.
Facebook and other SNSs are a completely new universe
to young and middle-aged adults. AN patients share the
same age cohort. Therefore, SNS seems to be a relevant
way for affected persons and caregivers to communicate
and get into social and therapeutic contact. The therapist
should be aware that for patients with eating disorders
SNSs are common and life without them often is
unimaginable. SNS offers chances for therapists and
patients. To what extent SNS could, must, or must not be
integrated into psychotherapeutic strategies should be
assessed systematically in future studies. In this study, we
focused on the activity and structure of AN-related com-
munication on Facebook. After this initial description,
further studies with the focus on qualitative research should
be pursued. Profiles of individuals should be examined in
more detail to identify possible approaches that might be
useful for clinicians and psychotherapists. Researchers and
care-giving institutions dealing with eating disorders
should be aware of the existence, possibilities, dysfunc-
tions, and influences of SNS.
Conflict of interest All authors certify that there is no actual or
potential conflict of interest in relation to this article.
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