Reducing eating disorder symptoms and risk factors using the internet: A meta-analytic review

Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design.

OBJECTIVE

This study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included.

METHODS

A literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes.

RESULTS

Digital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: χ21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results.

CONCLUSIONS

There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions.

TRIAL REGISTRATION

PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060.

Predictors, mediators, and moderators of response to digital interventions for eating disorders: A systematic review

OBJECTIVE

Digital interventions show promise as an effective prevention or self-management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs.

METHOD

Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop-out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention-focused) and samples with a formally diagnosed ED (typically treatment-focused).

RESULTS

Eighty-six studies were included. For studies recruiting samples without a formal diagnosis (n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged (n = 16), of which no reliable predictors, moderators, or mediators were identified.

DISCUSSION

It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality.

PUBLIC SIGNIFICANCE

Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

INTRODUCTION

Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.

OBJECTIVE

To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.

METHODS

Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.

RESULTS

Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.

CONCLUSIONS

Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

Effectiveness of an e-Health Quasi-Randomized Controlled Universal Prevention Program for Eating Disorders in Spanish Adolescents

Eating disorders (EDs) and sub-threshold conditions are prevalent in the adolescent population. Unfortunately, most preventive interventions have been targeted at emerging adults and the effectiveness of online prevention programs has yet to be determined in adolescents. This study sought to examine the short-term effectiveness of a universal e-Health psychoeducational prevention program for EDs compared to a control (non-intervention) group in Spanish adolescents. Using a quasi-randomized trial design, a total of 161 [% girls: 45.96; Mage(SD) = 12.43 (0.43)] adolescents from 5 participating schools were allocated to two intervention arms: (1) psychoeducational intervention (n = 79) and (2) wait-list control (n = 82). The intervention was delivered over 3 months through 3 modules that were accessible 24/7 and 3 school sessions guided by the students´ tutors focusing on nutrition, promoting a healthy lifestyle, mitigating body concerns, and social pressures. Participants completed an online assessment battery including the Eating Attitudes Test (EAT-26) and measures of self-esteem, family disruption, compliance with the Mediterranean diet, and lifestyle. Correlational analysis showed small to moderate relationships between self-esteem and family function (rho = 0.413, p = 0.001), BMI (body mass index) and the EAT-26 dieting subscale (rho = 0.417, p = 0.001), physical activity and the bulimia subscale (rho =  - 0.237, p = 0.003), and self-esteem and the dieting subscale (rho =  - 0.223, p = 0.004). At the post-intervention assessment, the intervention group showed a statistically significant reduction in ED risk (EAT-26) (d =  - 0.323, p = 0.040) and the oral control subscale (d = 0.327, p = 0.038). The e-health intervention including tutor-led digital components was effective for reducing ED risk in children. Results must be interpreted with caution due to the low statistical power and the limited sample size. Large scale randomized controlled trials with longer follow-ups will be needed to bolster the evidence.

Effect of modernized collaborative care for depression on brain-derived neurotrophic factor (BDNF) and depressive symptom clusters: Data from the eIMPACT trial

Brain-derived neurotrophic factor (BDNF) levels are lower in people with depression and are normalized following pharmacological treatment. However, it is unknown if psychological treatments for depression improve BDNF and if change in BDNF is a mediator of intervention effects on depressive symptoms. Therefore, using data from the eIMPACT trial, we sought to determine the effect of modernized collaborative care for depression on 12-month changes in BDNF and cognitive/affective and somatic depressive symptom clusters and to examine whether BDNF changes mediate intervention effects on depressive symptoms. 216 primary care patients with depression from a safety net healthcare system were randomized to 12 months of the eIMPACT intervention (internet cognitive-behavioral therapy [CBT], telephonic CBT, and select antidepressant medications) or usual primary care. Plasma BDNF was measured with commercially available kits, and depressive symptom clusters were assessed by the Patient Health Questionnaire-9. The intervention did not influence BDNF but did improve both the cognitive/affective and somatic clusters over 12 months. Changes in BDNF did not mediate the intervention effect on either cluster. Our findings suggest that modernized collaborative care is an effective treatment for both the cognitive/affective and somatic symptoms of depression and that the mechanism of action is not improvements in BDNF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02458690.

Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives

OBJECTIVE

A significant treatment gap exists between persons affected by eating disorders (ED), and those engaging with treatment services. This systematic review aims to provide a thorough understanding of the barriers and facilitators affecting eating disorder treatment engagement, including a synthesis of the perspectives of patients, caregivers and healthcare professionals.

METHOD

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were retrieved from three databases (PubMed, PsycInfo, Web of Science) and were screened and assessed independently by two raters. A thematic analysis was completed to determine the key barriers and facilitators reported by the included studies.

RESULTS

A total of 73 studies were included. From these studies, 12 barriers and 13 facilitators were identified. Patients reported stigma, shame and guilt as the most prominent barrier affecting their engagement with treatment services. Meanwhile, caregivers and healthcare professionals reported a lack of eating disorder knowledge of clinicians as the most important barrier. Positive social support was cited as the most prominent facilitator to promote help-seeking.

DISCUSSION

Patients, caregivers and healthcare professionals experience a variety of barriers and facilitators to treatment uptake for ED. Interventions addressing barriers and facilitators could increase treatment engagement, including anti-stigma campaigns and positive peer-support interventions.

The acceptability, feasibility, and preliminary efficacy of a supported online self-help treatment program for binge-eating disorder

Introduction

Studies in transdiagnostic eating disorder (ED) samples suggest supported online self-help programs (eTherapies) are effective and may improve access to treatment; however, their evaluation in those with binge-eating disorder (BED) is limited. Given BED's high prevalence and low levels of treatment uptake, further eTherapy evaluation is needed to broaden access to effective, evidence-based treatment options. The aim of this study was to investigate the acceptability, feasibility, and preliminary efficacy of a supported eTherapy for those with BED or subthreshold BED, and to examine symptom change across the duration of therapy.

Method

Nineteen women with BED completed a supported, 10-session Cognitive Behavioural Therapy-based eTherapy in an uncontrolled, pre-post, and 3 months follow up intervention study. Key outcomes were assessed by the Eating Disorder Examination Questionnaire (EDE-Q): objective binge episode (OBE) frequency and ED psychopathology. Feasibility was evaluated via program adherence and dropout, whilst acceptability was assessed through participant feedback post-treatment. Weekly symptom change (ED psychopathology) during treatment was assessed by the Eating Disorder Examination - Questionnaire Short (EDE-QS).

Results

Generalised estimating equations showed statistically and clinically significant reductions in OBEs and ED psychopathology (large effects) post-treatment, with these decreases maintained at follow up. Across weekly assessment, a marked slowing in the rate of change in ED psychopathology was observed after four sessions of the program. Program feasibility was high (i.e., 84% of content completed), as was program acceptability (i.e., 93% of participants expressed high levels of satisfaction).

Discussion

These results support the acceptability, feasibility, and preliminary efficacy of a supported eTherapy program for those with BED and suggest the variability of symptom change across the duration of therapy. Future research should further investigate findings in an adequately powered randomised controlled trial.

Predictors and moderators of three online interventions for eating disorder symptoms in a randomized controlled trial

OBJECTIVE

To optimize treatment recommendations for eating disorders, it is important to investigate whether some individuals may benefit more (or less) from certain treatments. The current study explored predictors and moderators of an automated online self-help intervention "Featback" and online support from a recovered expert patient.

METHODS

Data were used from a randomized controlled trial. For a period of 8 weeks, participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, (2) chat or e-mail support from an expert patient, (3) Featback with expert-patient support, and (4) a waitlist. A mixed-effects partitioning method was used to see if age, educational level, BMI, motivation to change, treatment history, duration of eating disorder, number of binge eating episodes in the past month, eating disorder pathology, self-efficacy, anxiety and depression, social support, or self-esteem predicted or moderated intervention outcomes in terms of eating disorder symptoms (primary outcome), and symptoms of anxiety and depression (secondary outcome).

RESULTS

Higher baseline social support predicted less eating disorder symptoms 8 weeks later, regardless of condition. No variables emerged as moderator for eating disorder symptoms. Participants in the three active conditions who had not received previous eating disorder treatment, experienced larger reductions in anxiety and depression symptoms.

DISCUSSION

The investigated online low-threshold interventions were especially beneficial for treatment-naïve individuals, but only in terms of secondary outcomes, making them well-suited for early intervention. The study results also highlight the importance of a supportive environment for individuals with eating disorder symptoms.

PUBLIC SIGNIFICANCE

To optimize treatment recommendations it is important to investigate what works for whom. For an internet-based intervention for eating disorders developed in the Netherlands, individuals who had never received eating disorder treatment seemed to benefit more from the intervention than those who had received eating disorder treatment, because they experienced larger reductions in symptoms of depression and anxiety. Stronger feelings of social support were related to less eating disorder symptoms in the future.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

Days between sessions predict attrition in text-based internet intervention of Binge Eating Disorder

BACKGROUND

The number of days between treatment sessions is often overlooked as a predictor of attrition in psychotherapy. In text-based Internet interventions, days between sessions may be a simple yet powerful predictor of attrition.

OBJECTIVE

We hypothesized that a larger number of days between sessions increased the likelihood of attrition among participants with Binge Eating Disorder (BED) in a 12-session Internet-based cognitive behavioral therapy (iCBT) program. Participants could work on the sessions whenever convenient for them and received written support from a psychologist.

MATERIAL AND METHODS

We compared 201 adult participants with mild to moderate BED (85 non-completers and 116 completers) on the number of days between sessions to predict attrition rates.

RESULTS

Mixed model binomial logistic regression showed that non-completers spent significantly more days between sessions across the first four treatment sessions (1-4) when controlling for age, gender, and intake measures of BMI, BED, overall health status (EQ VAS), and depression symptoms (MDI) (OR = 1.042, p < .001). Age (OR = 0.976, p < .001) and EQ VAS (OR = 0.984, p < .001) were also significant. The risk of attrition increased by 4.2 % for each additional day participants spent completing a session.A receiver operating characteristic (ROC) curve analysis showed that classification accuracy increased across sessions from 61.1 % in session 1 and 65.7 % in session 2 to 68.8 % in session 3 and 73.2 % in session 4. The optimal cut-off point in session 4 was 17.5 days, which detected 60.4 % of non-completers (sensitivity) and 78.4 % of completers (specificity).An exploratory repeated measures of ANOVA of days between sessions showed a significant within-subjects effect, where both non-completers and completers spent more days between sessions as they progressed from sessions 1 through 4 (F = 20.54, df = 3, p < .001). There was no interaction effect, suggesting that the increase in slope did not differ between non-completers and completers.

CONCLUSIONS

Participants spending more days between sessions are at increased risk of dropping out of treatment. This may have important implications for identifying measures to reduce attrition, e.g., intensifying interventions through automated reminders or therapist messages. Our findings may have important transdiagnostic implications for text-based Internet interventions. Further studies should investigate the predictive value of days between sessions in other diagnoses.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

Accessibility of Psychological Treatments for Bulimia Nervosa: A Review of Efficacy and Engagement in Online Self-Help Treatments

Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.

Evaluating the feasibility and potential efficacy of a brief eTherapy for binge-eating disorder: A pilot study

OBJECTIVE

For those with binge-eating disorder (BED), access to evidence-based, face-to-face treatment is often constrained by clinician availability and high treatment costs. Emerging evidence suggests online therapy (eTherapy) may navigate these barriers and reduce binge-eating symptomatology; however, less evaluation has been done in those with BED, particularly with briefer programs targeting early change. This study investigated the feasibility and potential efficacy of a brief, supported eTherapy in those with BED or subthreshold BED.

METHOD

Participants were 19 women with BED who completed a four-session eTherapy. This was a single-arm, pre-post intervention study, with participants completing weekly content and attending telehealth sessions. Key outcomes were assessed by the Eating Disorder Examination Questionnaire-Short (EDE-QS): objective binge episode days, loss of control over eating days, and eating disorder (ED) psychopathology via a total EDE-QS score.

RESULTS

Generalized and linear mixed models showed significantly reduced loss of control over eating days and ED psychopathology. Program feasibility was high, with strong program adherence and a below average attrition rate.

DISCUSSION

Pilot results support the feasibility and potential efficacy of a brief, behavioral-focused eTherapy program in reducing ED pathology in those with BED. Future research should further investigate findings in an adequately powered randomized controlled trial.

PUBLIC SIGNIFICANCE

This study suggests that a brief, behavioral-focused online therapy, guided by non-expert clinicians, can be successfully administered to those with binge-eating disorder (BED) and may be efficacious at reducing eating disorder and other related symptomatology. Brief eTherapies that are effective, accessible, and rapidly available may facilitate earlier intervention in illness and improve treatment outcomes for individuals who experience this common and distressing disorder.

Informing mHealth and Web-Based Eating Disorder Interventions: Combining Lived Experience Perspectives With Design Thinking Approaches

BACKGROUND

App-based interventions designed to prevent and treat eating disorders have considerable potential to overcome known barriers to treatment seeking. Existing apps have shown efficacy in terms of symptom reduction; however, uptake and retention issues are common. To ensure that apps meet the needs and preferences of those for whom they were designed, it is critical to understand the lived experience of potential users and involve them in the process of design, development, and delivery. However, few app-based interventions are pretested on and co-designed with end users before randomized controlled trials.

OBJECTIVE

To address the issue, this study used a highly novel design thinking approach to provide the context and a lived experience perspective of the end user, thus allowing for a deeper level of understanding.

METHODS

In total, 7 young women (mean age 25.83, SD 5.34, range 21-33 years) who self-identified as having a history of body image issues or eating disorders were recruited. Participants were interviewed about their lived experience of body image and eating disorders and reported their needs and preferences for app-based eating disorder interventions. Traditional (thematic analysis) and novel (empathy mapping; visually depicting and empathizing with the user's personal experience) analyses were performed, providing a lived experience perspective of eating disorders and identifying the needs and preferences of this population in relation to app-based interventions for eating disorders. Key challenges and opportunities for app-based eating disorder interventions were also identified.

RESULTS

Findings highlighted the importance of understanding and identifying problematic eating disorder symptoms for the user, helpful practices for recovery that identify personal values and goals, the role of social support in facilitating hope, and aspects of usability to promote continued engagement and recovery.

CONCLUSIONS

Practical guidance and recommendations are described for those developing app-based eating disorder interventions. These findings have the potential to inform practices to enhance participant uptake and retention in the context of app-based interventions for this population.

Effectiveness of an online self-help program, expert-patient support, and their combination for eating disorders: Results from a randomized controlled trial

OBJECTIVE

Many individuals with an eating disorder do not receive appropriate care. Low-threshold interventions could help bridge this treatment gap. The study aim was to evaluate the effectiveness of Featback, a fully automated online self-help intervention, online expert-patient support and their combination.

METHOD

A randomized controlled trial with a 12-month follow-up period was conducted. Participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, a fully automated online self-help intervention, (2) chat or email support from a recovered expert patient, (3) Featback with expert-patient support and (4) a waiting list control condition. The intervention period was 8 weeks and there was a total of six online assessments. The main outcome constituted reduction of eating disorder symptoms over time.

RESULTS

Three hundred fifty five participants, of whom 43% had never received eating disorder treatment, were randomized. The three active interventions were superior to a waitlist in reducing eating disorder symptoms (d = -0.38), with no significant difference in effectiveness between the three interventions. Participants in conditions with expert-patient support were more satisfied with the intervention.

DISCUSSION

Internet-based self-help, expert-patient support and their combination were effective in reducing eating disorder symptoms compared to a waiting list control condition. Guidance improved satisfaction with the internet intervention but not its effectiveness. Low-threshold interventions such as Featback and expert-patient support can reduce eating disorder symptoms and reach the large group of underserved individuals, complementing existing forms of eating disorder treatment.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with eating-related problems who received (1) a fully automated internet-based intervention, (2) chat and e-mail support by a recovered individual or (3) their combination, experienced stronger reductions in eating disorder symptoms than those who received (4) usual care. Such brief and easy-access interventions play an important role in reaching individuals who are currently not reached by other forms of treatment.

Cognitive training via a mobile application to reduce some forms of body dissatisfaction in young females at high-risk for body image disorders: A randomized controlled trial

Body dissatisfaction has been related to Body Image Disorders (BIDs) such as Eating Disorders (EDs) and Body Dysmorphic Disorder (BDD). This study investigates the efficacy of a mHealth app in reducing body dissatisfaction, BDD/ED symptoms and related features. Ninety-five women who were identified as high-risk of developing BIDs (using the Structured Clinical Interview for DSM-5) were randomized into: immediate-use App (iApp group; n = 47) and delayed-use App (dApp group; n = 48). The iApp group started using the app at baseline for 16 days (T1). The dApp group started using the app at T1 for 16 days. Participants completed questionnaires at baseline (T0), 16 days from baseline (T1), and 32 days from baseline (T2). Repeated measure Multivariate Analysis of Variance (MANOVA) showed Group (iApp vs. dApp) × Time (T0 vs. T1) interactions indicating decrease in BDD symptoms and body dissatisfaction related to EDs in the iApp group at T1. The Reliable Change Index indicated changes on extreme body dissatisfaction/BDD symptoms for 34.74% of participants. Although preliminary, these findings highlight that a mHeatlh app might reduce BDD symptoms and body dissatisfaction related to EDs in women at high-risk for BIDs. Effects on ED symptoms and associated features seem more limited.

Effectiveness of recruitment strategies for a social media literacy E-intervention for young adults with body dissatisfaction: cost, time, diversity, and completion

Digital interventions are becoming increasingly popular for the treatment of body dissatisfaction and eating disorders. However, participant recruitment to online interventions poses a challenge. This study examined differences between a variety of recruitment strategies to a digital intervention in terms of number of participants recruited, cost, study personnel time, completion rates, and demographic characteristics of participants.Participants (N = 395) aged 18-25 years (79.5% women) were recruited to take part in an online body image intervention and asked how they heard about the program (e.g., through Facebook, a flyer on a university campus). Strategies of recruitment, including researcher time required and cost were recorded throughout the project. Cost and time effectiveness, study and intervention completion rates, and participant demographics for each recruitment approach were explored.Facebook paid advertising recruited n = 241 participants (78.0% women), with $29.81 cost per completer, and researcher time per completer at 2.41 minutes. Facebook unpaid advertising was also effective, recruiting n = 130 participants (78.5% women), with $0.00 external cost per completer, and time per completer at 20.43 minutes. Other strategies, both online and face-to-face, were far less effective in recruiting participants. Men proved difficult to recruit using any strategy.Facebook advertising was an effective tool for recruiting young adults to this online intervention, although further research should identify effective strategies to recruit men for similar interventions.

Cost-effectiveness of three internet-based interventions for eating disorders: A randomized controlled trial

OBJECTIVE

The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition.

METHOD

An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration.

RESULTS

No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (€16,741) while the highest costs were seen in the care-as-usual condition (€28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values.

DISCUSSION

Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment.

PUBLIC SIGNIFICANCE STATEMENT

Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

Virtual prevention of eating disorders in children, adolescents, and emerging adults: a scoping review

BACKGROUND

During the COVID-19 pandemic, there was a necessity for eating disorder (ED) outpatient treatment to be delivered virtually. Given this transition, and the surge in new ED cases, there was an urgent need to investigate virtually delivered ED prevention programs. This review aimed to identify the available evidence on virtual ED prevention programs for children, adolescents, and emerging adults.

METHOD

Using scoping review methodology, seven databases were searched for studies published from January 2000 to April 2021 reporting on virtually delivered ED prevention interventions for children and adolescents (< 18 years) and emerging adults (18-25 years). Studies were excluded if they contained adults (> 25 years) and individuals with clinical ED diagnoses. Abstracts and full-text papers were reviewed independently by two reviewers. Data was extracted on study type, methodology, age, sample size, virtual intervention, outcomes, and results. In April 2022, we used a forward citation chaining process to identify any relevant articles from April 2021 to April 2022.

RESULTS

Of 5129 unique studies identified, 67 met eligibility criteria, which included asynchronous (n = 35) and synchronous (n = 18) internet-based programs, other e-technology including mobile apps (n = 3) and text messaging interventions (n = 1), computer-based programs (n = 6), and online caregiver interventions focused on child outcomes (n = 4). Few studies mainly included children and adolescents (n = 18), whereas the vast majority included emerging adults (n = 49). For children and adolescents, the most widely researched programs were Student Bodies and its adapted versions (n = 4), eBody Project (n = 2), and Parents Act Now (n = 2). For emerging adults, the most widely researched programs were Student Bodies and its adapted versions (n = 16), eBody Project (n = 6) and Expand Your Horizon (n = 4). These interventions were effective at reducing various symptoms and ED risk. Some studies demonstrated that virtual prevention intervention efficacy resembled in-person delivery.

CONCLUSION

Virtual prevention interventions for EDs can be effective, however more research is needed studying their impact on children and adolescents and on improving access for vulnerable groups. Additional efficacy studies are required, such as for text messaging and mobile app ED prevention interventions. Evidence-based recommendations for virtual ED prevention for children, adolescents, and emerging adults at-risk for EDs should be prioritized.

Efficacy of a transdiagnostic cognitive-behavioral intervention for eating disorder psychopathology delivered through a smartphone app: a randomized controlled trial

BACKGROUND

Although effective treatments exist for diagnostic and subthreshold-level eating disorders (EDs), a significant proportion of affected individuals do not receive help. Interventions translated for delivery through smartphone apps may be one solution towards reducing this treatment gap. However, evidence for the efficacy of smartphones apps for EDs is lacking. We developed a smartphone app based on the principles and techniques of transdiagnostic cognitive-behavioral therapy for EDs and evaluated it through a pre-registered randomized controlled trial.

METHODS

Symptomatic individuals (those who reported the presence of binge eating) were randomly assigned to the app (n = 197) or waiting list (n = 195). Of the total sample, 42 and 31% exhibited diagnostic-level bulimia nervosa and binge-eating disorder symptoms, respectively. Assessments took place at baseline, 4 weeks, and 8 weeks post-randomization. Analyses were intention-to-treat. The primary outcome was global levels of ED psychopathology. Secondary outcomes were other ED symptoms, impairment, and distress.

RESULTS

Intervention participants reported greater reductions in global ED psychopathology than the control group at post-test (d = -0.80). Significant effects were also observed for secondary outcomes (d's = -0.30 to -0.74), except compensatory behavior frequency. Symptom levels remained stable at follow-up. Participants were largely satisfied with the app, although the overall post-test attrition rate was 35%.

CONCLUSION

Findings highlight the potential for this app to serve as a cost-effective and easily accessible intervention for those who cannot receive standard treatment. The capacity for apps to be flexibly integrated within current models of mental health care delivery may prove vital for addressing the unmet needs of people with EDs.

Does the Method of Content Delivery Matter? Randomized Controlled Comparison of an Internet-Based Intervention for Eating Disorder Symptoms With and Without Interactive Functionality

Despite their potential as a scalable, cost-effective intervention format, self-guided Internet-based interventions for eating disorder (ED) symptoms continue to be associated with suboptimal rates of adherence and retention. Improving this may depend on the design of an Internet intervention and its method of content delivery, with interactive programs expected to be more engaging than static, text-based programs. However, causal evidence for the added benefits of interactive functionality is lacking. We conducted a randomized controlled comparison of an Internet-based intervention for ED symptoms with and without interactive functionality. Participants were randomized to a 4-week interactive (n = 148) or static (n = 145) version of an Internet-based, cognitive-behavioral program. The interactive version included diverse multimedia content delivery channels (video tutorials, graphics, written text), a smartphone app allowing users to complete the required homework exercises digitally (quizzes, symptom tracking, self-assessments), and progress monitoring features. The static version delivered identical intervention content but only via written text, and contained none of those interactive features. Dropout rates were high overall (58%), but were significantly-yet slightly-lower for the interactive (51%) compared to the static intervention (65%). There were no significant differences in adherence rates and symptom-level improvements between the two conditions. Adding basic interactive functionality to a digital intervention may help with study retention. However, present findings challenge prior speculations that interactive features are crucial for enhancing user engagement and symptom improvement.

Universal programs to prevent eating disorders in children and adolescents: A scoping review of ethical, legal, organizational and social impacts

BACKGROUND

Appropriate and timely consideration of ethical, legal, organizational, and social issues in universal preventive programs for eating disorders (UPPED) are relevant for the approval, funding and implementation of health-policy decision making.

OBJECTIVE

To identify and analyse the ethical, legal, organizational, and social aspects involved in interventions aimed at the universal prevention of eating disorders (ED) in children, pre-adolescents and adolescents in the school settings.

METHOD

A scoping review of the literature was carried out. MEDLINE, EMBASE, CENTRAL, PsycINFO, and Social Science Citation Index were searched for studies published in English or Spanish. The quality of the studies was assessed using specific scales for each study design.

RESULTS

Fourteen studies were included: one scoping review; four narrative reviews, six observational studies, two qualitative studies, and one mixed methods study. Results were narratively synthesised according to: (1) equity; (2) gender perspective; (3) potential harm; (4) participants and facilitators profile; (5) feasibility; and (6) acceptability.

CONCLUSIONS

Interactive programs with relevant contents for participants have greater acceptability. Programs focussed on developing competencies can reduce the risk of potential harm. Incorporating a gender perspective contributes to improving equity. Teachers with prior training in ED are well suited as facilitators of these programs.

Text based internet intervention of Binge Eating Disorder (BED): Words per message is associated with treatment adherence

BACKGROUND

Some evidence suggests that in internet-based cognitive behavioral therapy (iCBT) the likelihood of adherence is increased when patients write longer messages to the therapist in the program. This association has not previously been investigated in iCBT for Binge Eating Disorder (BED).

OBJECTIVE

In this study, we hypothesized that the number of words written by patients with mild to moderate BED was associated with increased likelihood of treatment completion in a text-based iCBT program.

MATERIAL AND METHODS

We compared 143 BED patients (92 completers and 51 non-completers) on the number of messages and words written to their therapist during the treatment.

RESULTS

Completers wrote significantly more words per message (words/message) than non-completers. The results remained significant after controlling for gender, age, educational level, marital status, children, source of income and intake measures of BED, BMI and depression symptoms (Wald = 14.48, p < .001). The odds ratio of completion increased by 1.5% for each additional word patients wrote per message (OR = 1.015). The model showed a 72.4% classification accuracy, and an optimal cut-off point of 68.99 words/message for differentiating completers and non-completers. The model accurately identified 80.9% of completers (sensitivity) and 54.9% of non-completers (specificity).

CONCLUSIONS

The number of words/message patients write may have important implications for ascertaining likelihood of adherence and improving adherence rates. From a clinical perspective, therapists should encourage patients to use the option of writing messages to the therapist. Words/message may prove to be a transdiagnostic predictor of treatment adherence in text based iCBT.

Systematic Review of Digital Interventions for Adolescent and Young Adult Women's Body Image

Background

A growing number of digital interventions have been developed to address a range of mental health issues including body image. Identifying effective interventions for body image is important given the prevalence of body image concerns and their associated negative outcomes among young women. This review aimed to critically evaluate current evidence on the use of digital interventions for adolescent and young adult women's body image.

Methods

A literature search was performed in November 2021 across three databases, PsychINFO, Web of Science and Pubmed to identify studies published with keywords and synonyms of "body image" and "digital interventions" that have been conducted with girls/women aged 10-25 years. Studies were included if they assessed a universal body image intervention delivered through a digital platform (e.g., web-based, mobile phone) and if they reported body image outcomes using validated measures. Two authors independently screened studies extracted data and assessed the quality of studies.

Results

Eight of 15 interventions were effective in improving at least one body image outcome from pre-post intervention; however, effect sizes were mostly small-medium, and few effects were maintained at follow-up. Studies were heterogeneous in terms of delivery format, duration, sample characteristics, quality, and outcomes.

Discussion

Findings suggest that digitally delivered interventions can effectively improve some body image outcomes in young women. Characteristics of effective studies are discussed and suggestions for future work on intervention development in this field are provided.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021281435, identifier CRD42021281435.

Recruitment, adherence and attrition challenges in internet-based indicated prevention programs for eating disorders: lessons learned from a randomised controlled trial of ProYouth OZ

BACKGROUND

Growing evidence supports the effectiveness of Internet-based prevention programs for eating disorders, but the adjunctive benefit of synchronous peer support has yet to be investigated. In the current study, a randomised controlled trial was conducted to evaluate the effectiveness of an indicated Internet-based prevention program (ProYouth OZ) with and without peer-to-peer support in reducing disordered eating behaviours and attitudes.

METHOD

Fifty young adults (18-25 years) with eating disorder symptoms were randomised to one of three study conditions: (1) ProYouth OZ (without peer-to-peer support), (2) ProYouth OZ Peers (with peer-to-peer support), and (3) a waitlist control group. Outcomes were assessed at three different time points. Eating disorder symptoms (primary outcome) were measured with the Eating Disorder Examination Questionnaire.

RESULTS

Of 415 screened participants, 73 (17.6%) were eligible and 213 (51.3%) excluded due to severe eating disorder symptoms. Fifteen participants (30%) completed the post-intervention survey. Of the two intervention groups, 20.6% failed to access any component of the program. Of 17 ProYouth OZ Peers participants, 58.8% attended at least one chat session, 20% attended 2-5 sessions, and 11.8% attended all six sessions. Due to limited outcome data, it was not possible to statistically examine between-group differences in outcomes. Visual inspection of individual profiles revealed that both ProYouth OZ Peers participants who completed the post-intervention survey showed a decrease in disordered eating compared with only one of the six completers in ProYouth OZ.

CONCLUSION

Findings highlight the challenges of trialling Internet-based eating disorder prevention programs in the community. The study identified a large group of emerging adults with eating disorders who were interested in an Internet-based program, suggesting a high level of unmet need. Future research on synchronous peer-to-peer support in Internet-based prevention for eating disorders is warranted. Further studies are required to identify optimal strategies for reaching this population (e.g., online vs. offline) and evaluating the effectiveness of a range of strategies for promoting engagement. Finally, there is an urgent need to develop innovative widely accessible interventions for individuals who experience clinically relevant eating disorder symptomatology but may not be ready or able to seek professional face-to-face treatment.

TRIAL REGISTRATION

ACTRN12615001250527, Registered 16 November 2015, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615001250527.

Eating disorders during the COVID-19 pandemic and quarantine: an overview of risks and recommendations for treatment and early intervention

Individuals with eating disorders (EDs) are at significant risk for increases in symptomatology and diminished treatment access during the COVID-19 pandemic. Environmental precautions to limit coronavirus spread have affected food availability and access to healthy coping mechanisms, and have contributed to weight-stigmatizing social media messages that may be uniquely harmful to those experiencing EDs. Additionally, changes in socialization and routine, stress, and experiences of trauma that are being experienced globally may be particularly deleterious to ED risk and recovery. This paper presents a brief review of the pertinent literature related to the risk of EDs in the context of COVID-19 and offers suggestions for modifying intervention efforts to accommodate the unique challenges individuals with EDs and providers may be experiencing in light of the ongoing public health crisis.

Indicated, Web-based Prevention for Women With Anorexia Nervosa Symptoms: A Randomised Controlled Efficacy Trial (Preprint)

Background

Although preventive interventions for eating disorders in general have shown promise, interventions specifically targeting individuals at risk for anorexia nervosa (AN) are lacking.

Objective

The aim of this study was to determine the efficacy of a guided, indicated web-based prevention program for women at risk for AN.

Methods

We conducted a randomized controlled efficacy trial for women at risk for AN. Assessments were carried out at baseline (before the intervention), after the intervention (10 weeks after baseline), and at 6- and 12-month follow-ups (FUs). A total of 168 women with low body weight (17.5 kg/m²≤BMI≤19 kg/m²) and high weight concerns or with normal body weight (19 kg/m²<BMI≤25 kg/m²), high weight concerns, and high restrained eating were recruited from 3 German universities as well as on the web and randomized to Student Bodies-AN (SB-AN; intervention group [IG]) or a wait-list control group (CG). The exclusion criteria were current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–based full-syndrome eating disorders and serious medical or mental problems. The interventions were a cognitive-behavioral guided web-based prevention program (SB-AN) over 10 weeks (IG) and a wait-list CG. The primary outcomes were clinically significant changes in disordered eating attitudes and behaviors and change in BMI at 12-month FU in the group of participants who were underweight. The secondary outcomes were new onset of eating disorders, symptoms of disordered eating, and associated psychopathology.

Results

Data were available for 81.5% (137/168) of the women after the intervention and for 69% (116/168) of the women at 12-month FU. At 12-month FU, the IG participants showed larger decreases in Eating Disorder Examination total scores (38/48, 79% vs 33/58, 57%) than the CG participants and the IG participants who were underweight also showed larger clinically relevant increases in BMI (15/31, 49% vs 10/32, 32%) than the CG participants, but these differences were not significant. In addition, after the intervention and at 12-month FU, we found a significant increase in continuously measured BMI for the participants who were underweight and significant improvements in disordered eating attitudes and behaviors (eg, restrained eating as well as weight and shape concerns). At all time points, the rates of new-onset eating disorder cases were (nonsignificantly) lower in the IG than in the CG and the reductions in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition–based eating disorder syndromes were (nonsignificantly) higher in the IG than in the CG.

Conclusions

SB-AN is the first preventive intervention shown to significantly reduce specific risk factors for, and symptoms of, AN and shows promise for reducing full-syndrome AN onset.

Trial Registration

ISRCTN Registry ISRCTN70380261; https://www.isrctn.com/ISRCTN70380261

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

BED-online: Acceptance and efficacy of an internet-based treatment for binge-eating disorder: A randomized clinical trial including waitlist conditions

Objective

Internet‐based guided self‐help (GSH) programs increase accessibility and utilization of evidence‐based treatments in binge‐eating disorder (BED). We evaluated acceptance and short as well as long‐term efficacy of our 8‐session internet‐based GSH program in a randomized clinical trial with an immediate treatment group, and two waitlist control groups, which differed with respect to whether patients received positive expectation induction during waiting or not.

Method

Sixty‐three patients (87% female, mean age 37.2 years) followed the eight‐session guided cognitive‐behavioural internet‐based program and three booster sessions in a randomized clinical trial design including an immediate treatment and two waitlist control conditions. Outcomes were treatment acceptance, number of weekly binge‐eating episodes, eating disorder pathology, depressiveness, and level of psychosocial functioning.

Results

Treatment satisfaction was high, even though 27% of all patients dropped out during the active treatment and 9.5% during the follow‐up period of 6 months. The treatment, in contrast to the waiting conditions, led to a significant reduction of weekly binge‐eating episodes from 3.4 to 1.7 with no apparent rebound effect during follow‐up. All other outcomes improved as well during active treatment. Email‐based positive expectation induction during waiting period prior to the treatment did not have an additional beneficial effect on the temporal course and thus treatment success, of binge episodes in this study.

Conclusion

This short internet‐based program was clearly accepted and highly effective regarding core features of BED. Dropout rates were higher in the active and lower in the follow‐up period. Positive expectations did not have an impact on treatment effects.

The present internet‐based guided self‐help program adds to the existing research regarding online treatment of binge‐eating disorder and is currently one of the two existing validated programs available in German language. It is based on an established cognitive‐behavioural treatment approach, shows high acceptance by patients and high efficacy after eight guided online sessions, thereby representing the shortest duration of currently evaluated treatments

During the internet‐based therapy, the number of weekly binge‐eating episodes, depressive symptoms, eating disorder pathology as well as impairments in psychosocial functioning all significantly decreased. These positive effects were maintained during follow‐up (6 months). Abstainer rate (no binge‐eating during last month) continued to increase during follow‐up with booster sessions

An email‐based pre‐treatment positive expectation induction did not alter the temporal course and thus treatment success, of binge episodes

Current state of scientific evidence on Internet-based interventions for the treatment of depression, anxiety, eating disorders and substance abuse: an overview of systematic reviews and meta-analyses

BACKGROUND

ICare represents a consortium of European Investigators examining the effects of online mental health care for a variety of common mental health disorders provided in a variety of settings. This article provides an overview of the evidence of effectiveness for Internet-based treatment for four common mental health disorders that are the focus of much of this work: depression, anxiety, substance abuse and eating disorders.

METHODS

The overview focused primarily on systematic reviews and meta-analyses identified through PubMed (Ovid) and other databases and published in English. Given the large number of reviews specific to depression, anxiety, substance abuse and/or eating disorders, we did not focus on reviews that examined the effects of Internet-based interventions on mental health disorders in general. Each article was reviewed and summarized by one of the senior authors, and this review was then reviewed by the other senior authors. We did not address issues of prevention, cost-effectiveness, implementation or dissemination, as these are addressed in other reviews in this supplement.

RESULTS

Across Internet-based intervention studies addressing depression, anxiety, substance abuse and eating disorders primarily among adults, almost all reviews and meta-analyses found that these interventions successfully reduce symptoms and are efficacious treatments. Generally, effect sizes for Internet-based interventions treating eating disorders and substance abuse are lower compared with interventions for depression and anxiety.

CONCLUSIONS

Given the effectiveness of Internet-based interventions to reduce symptoms of these common mental health disorders, efforts are needed to examine issues of how they can be best disseminated and implemented in a variety of health care and other settings.

Stakeholder consultation to facilitate implementation of interventions for prevention and promotion in mental health in Europe: introducing the design of the ICare Stakeholder Survey

BACKGROUND

Online interventions to prevent mental health problems have proven to be effective. However, knowledge about their implementation in real-world practice as well as for dissemination to the target groups in different settings is scarce. The goal of the 'ICare' network is to establish a comprehensive model of eMental-health service delivery in and across different European countries. Since implementation and dissemination are influenced by many contextual factors, in the first phase of ICare a stakeholder survey was conducted. The survey aim was to explore stakeholders' experiences, needs and attitudes regarding Internet-based prevention of mental health problems and hindering and fostering factors for implementation and dissemination. This article is part of a supplement and describes the design of the stakeholder survey. Survey results are published in separate articles in the same supplement.

METHODS

Based on a literature review and the individual characteristics of the ICare interventions, stakeholder groups were identified in different settings across six European countries. The RE-AIM framework guided the development of the research questions and survey instruments. A concurrent mixed methods design was applied comprising focus groups with the intended target groups of ICare interventions, an online questionnaire with potential facilitators/delivery staff and semi-structured interviews with policy makers.

CONCLUSION

The challenge was to develop a design that allowed flexibility but at the same did not jeopardize the validity of the study. Implications drawn from this survey are not restricted to specific preventive interventions but will provide general information on how online mental illness prevention can be best implemented in various settings.

A systematic review of reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adults

BACKGROUND

There is a growing body of research and evidence for the efficacy of Internet-based eating disorder (ED) prevention interventions for adults. However, much less is known about the reach, adoption, implementation and maintenance of these interventions. The RE-AIM (reach, efficacy/effectiveness, adoption, implementation, maintenance) model provides a framework to systematically assess this information.

METHODS

A literature search was conducted in PubMed, Web of Science and PsycINFO for articles published between 2000 and 2019. Additionally, reference lists of the studies included and existing reviews published until the end of 2020 were searched. Sixty original articles describing 54 individual studies fulfilled inclusion criteria. Data were extracted for a total of 43 RE-AIM indicators for each study. Fostering and hindering factors for reach, adoption, implementation and maintenance were assessed qualitatively.

RESULTS

Overall reporting rates were best for the RE-AIM dimensions reach (62.6%), implementation (57.0%) and effectiveness (54.2%), while adoption (24.2%) and maintenance (21.5%) had comparatively low overall reporting rates. Reporting on indicators of internal validity, such as sample size, effects or description of interventions was better than indicators relevant for dissemination and implementation in real-world settings, e.g. characteristics of non-participants, characteristics and representativeness of settings, and data to estimate cost.

CONCLUSIONS

Because most Internet-based ED prevention interventions are provided in a research-funded context, little is known about their public health impact. Better reporting of factors determining external validity is needed to inform dissemination and implementation of these interventions.

Stakeholders' perspectives on online interventions to improve mental health in eating disorder patients and carers in Germany

BACKGROUND

Eating disorders are causing severe consequences for those affected as well as a high burden for their carers. Although there is a substantial need for psychological assistance, different factors are hindering access to support. Internet-based interventions can help to overcome these barriers. To date, there is only little knowledge on attitudes of potential users, facilitators (e.g. psychologists) and decision makers (e.g. health insurances) regarding these interventions.

METHODS

We conducted focus groups with potential users (N = 30) and semi-structured interviews with potential decision makers (N = 4). Potential facilitators (N = 41) participated in an online survey. Stakeholders' experiences, attitudes, and their needs regarding Internet-based interventions for eating disorder patients and carers were assessed. Furthermore, hindering and fostering factors related to reach, adoption, implementation and maintenance were analyzed.

RESULTS

About two-thirds of the participating facilitators have heard or read about Internet-based interventions in general. In contrast, the other stakeholders mentioned to have no or little experience with such interventions. Factors like anonymity, availability and cost-effectiveness were seen as major advantages. Also disadvantages, e.g. lack of personal contact, limitations by disease severity and concerns on data safety, were mentioned. Stakeholders stated the need for interventions which are usable, evidence-based, tailored and provide personal support.

CONCLUSION

Stakeholders considered Internet-based programmes to have more advantages than disadvantages. Effort should be put in providing systematic education to address prejudices. When offering an online intervention, stakeholders' needs, as well as a continuous evaluation and adaptation, have to be taken into account.

Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol

About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.

Effectiveness of an Internet Dissonance-Based Eating Disorder Prevention Intervention Among Body-Dissatisfied Young Chinese Women

Body image disturbances are widespread in highly populated, rapidly developing Asian nations such as China, but there are severe shortages of practitioners qualified to treat these issues. In such contexts, validated online interventions offer a potentially viable approach for addressing the lack of treatment resources. In this study, we evaluated effects of the eBody Project, an online, dissonance-based eating disorder prevention program, on functioning among body-dissatisfied young Chinese women. Participating women were randomly assigned to the 6-week eBody Project intervention (n = 191) versus an education brochure control condition (n = 181). Self-report assessments of eating disorder risk factors (body dissatisfaction, thin ideal internalization, depressive symptoms, restrained eating), self-esteem, body appreciation, and disordered eating were completed at baseline, posttreatment, and a 6-month follow-up. There were no intervention differences on outcomes before treatment but eBody Project women experienced significantly larger improvements on all outcomes following treatment and/or at follow-up compared to controls; corresponding effect sizes were small to medium. Results indicated the eBody Project program is a promising intervention for young women at risk for eating disorders in China and provide foundations for broad implementation in low- and middle-income countries where resources for in-person therapy and supervision are limited or unavailable altogether.

Cognitive Behavioral Training Using a Mobile Application Reduces Body Image-Related Symptoms in High-Risk Female University Students: A Randomized Controlled Study

Body dissatisfaction is prevalent in young women, and is associated with symptoms of body dysmorphic disorder (BDD) and eating disorders (EDs). The aim of the study was to assess the efficacy of a mobile application, based on cognitive behavioral principles, in reducing body dissatisfaction and BDD/ED symptoms in female university students considered at high-risk of developing body image disorders (BIDs). Fifty university students at high-risk of developing BIDs (using self-report questionnaires assessing BIDs and the Structured Clinical Interview for DSM-5 Clinical Version) were randomized in two groups: immediate-use App group (iApp group; n = 25) and delayed-use App group (dApp group; n = 25). The iApp group started using the app at baseline for 16 days (T0 to T1). The dApp group waited for 16 days before starting to use the app (T1 to T2). Participants completed questionnaires at baseline (T0), 16 days from baseline (T1), and 32 days from baseline (T2). Repeated measure Analyses of Variance (ANOVAs) showed a Group (iApp vs. dApp) × Time (T0 vs. T1) interaction on BDD symptoms indicating medium effect size (partial eta squared) reductions in the iApp group compared to dApp group at T1; post-intervention means for BDD symptoms were under the cut-off for extreme body dissatisfaction/BDD symptoms in both groups. Pertaining to ED symptoms, no significant Group × Time interaction was detected. Training 3 minutes a day for 16 days with a CBT-based mobile application may lead to reductions in some forms of body dissatisfaction, including BDD symptoms in female university students at high-risk of developing BIDs. On the other hand, effects of the intervention on ED symptoms seem more limited.

Adolescents and young adults engaged with pro-eating disorder social media: eating disorder and comorbid psychopathology, health care utilization, treatment barriers, and opinions on harnessing technology for treatment

PURPOSE

The purpose of this study was to examine exposure (i.e., seeing, following, posting) to body image content emphasizing a thin ideal on various social media platforms and probable eating disorder (ED) diagnoses, ED-related quality of life, and psychiatric comorbidities (i.e., depression, anxiety) among adolescents and young adult females recruited via social media who endorsed viewing and/or posting pro-ED online content. We also investigated health care utilization, treatment barriers, and opinions on harnessing technology for treatment.

METHODS

Participants were 405 adolescent and young adult females engaged with pro-ED social media. We reported on study constructs for the sample as a whole, as well as on differences between age groups.

RESULTS

Eighty-four percent of participants' self-reported symptoms were consistent with a clinical/subclinical ED, and this was slightly more common among young adults. Participants endorsed reduced ED-related quality of life, as well as comorbid depression and anxiety. Among those with clinical/subclinical EDs, only 14% had received treatment. The most common treatment barriers were believing the problem was not serious enough and believing one should help themselves. The majority of participants approved of harnessing technology for treatment.

CONCLUSIONS

Results provide support for engagement with pro-ED online content serving as a potential indicator of ED symptoms and suggest promise for facilitating linkage from social media to technology-enhanced interventions.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

The role of body-esteem in academic functioning problems associated with eating disturbances

To explore the role of body-esteem and self-esteem in the occurrence of academic functioning problems associated with eating disturbances. Participants: 330 university students (aged 16-53 years) in Finland in 2016. Method: Interference with academic functioning measured with the Eating and Body Image Academic Interference Scale. Multivariable logistic regression analyses were performed to describe the relationship of body-esteem, global self-esteem, and age with academic functioning problems associated with eating disturbances. Results: The level of academic functioning problems was low. High appearance-esteem (OR = 0.26; 95% CI [0.14-0.48]) and a five-year increase in age (OR = 0.68; 95% CI [0.52-0.89]) provided protection against academic functioning problems, whereas high evaluations attributed to others about one's body and appearance increased the odds of such problems (OR = 2.25; 95% CI [1.41-3.59]). Conclusion: Problems in academic functioning may relate to problems in eating behavior, body image, and feelings about appearance.

Building resilience to body image triggers using brief cognitive training on a mobile application: A randomized controlled trial

OBJECTIVE

Body image disturbance (BID) is common among women, characterized by persistent and distressing appearance dissatisfaction, and linked with eating disorders. Although effective, cognitive behavioral therapy (CBT) delivered by trained professionals is not easily accessible. This randomized trial evaluated the effects of a CBT-based mobile application designed to increase resilience to body image triggers and reduce BID symptoms.

METHOD

A non-clinical sample of women (N = 90; M_age = 23.52) was randomized to use the mobile application for approximately 4 min of daily exercises for two weeks or to a control condition. Body image was measured at baseline, immediately after two weeks of mobile application use, and at 1-month follow-up. To examine whether using the application was associated with increased resilience to common BID triggers, participants completed an Instagram exposure resilience task upon completion and at 1-month follow-up.

RESULTS

Relative to those in the control condition, participants who used the application demonstrated increased resiliency and reduced BID symptoms. Theses effects were medium-to-large and were maintained at 1-month follow-up.

CONCLUSION

These results underscore the potential usefulness of brief, low-intensity, portable interventions in reducing BID symptoms and in increasing resilience to thin-ideal body messages often portrayed on social media.

Does a Facebook-enhanced Mindful Self-Compassion intervention improve body image? An evaluation study

This study evaluates a brief intervention aimed at improving body image. The intervention comprised a Mindful Self-Compassion workshop complemented by a group discussion on Facebook. Young women (M_age = 18.31), screened for body concerns, were allocated by university campus to a 50-minute workshop intervention (n = 42) or a waitlist control (n = 34). Following the workshop, participants in the intervention group utilized self-compassion techniques when experiencing appearance distress and posted about their experiences on a private Facebook group three times per week for two weeks. Findings showed that, relative to control, the intervention group experienced lower upward appearance comparison, social appearance anxiety, body dissatisfaction, and drive for thinness, and higher body appreciation and self-compassion, at posttest and 1-month follow-up. All effects, except those for body dissatisfaction, were held at 3-month follow-up. Additionally, common humanity predicted gains in body appreciation from pretest to posttest. The Mindful Self-Compassion intervention involving a Facebook group may have resonated with young women as it allowed them to share moments of self-compassionate body image experiences in a private and supportive environment.

Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial

Importance

Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap.

Objective

To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care.

Design, Setting, and Participants

This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019.

Interventions

Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care.

Main Outcomes and Measures

The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access.

Results

A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001).

Conclusions and Relevance

In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02076464.

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.

A survey study of attitudes toward, and preferences for, e-therapy interventions for eating disorder psychopathology

OBJECTIVE

E-therapy shows promise as a solution to the barriers that stand in the way of people receiving eating disorder (ED) treatment. Despite the potential for e-therapy to reduce the well-known treatment gap, little is known about public views and perspectives on this mode of intervention delivery. This study explored attitudes toward, and preferences for, e-therapy among individuals spanning the spectrum of eating pathology.

METHOD

Survey data assessing e-therapy attitudes and preferences were analyzed from 713 participants recruited from the public. Participants were categorized into one of five subgroups based on the type of self-reported ED symptoms and severity/risk level, ranging from high risk to a probable threshold or subthreshold ED.

RESULTS

Attitudes toward e-therapies appeared to be relatively positive; participants largely supported health care insurance coverage of costs for e-therapies, and were optimistic about the wide-ranging benefits of e-therapy. Although three-quarters of participants expressed a preference for face-to-face therapy, a significant percentage of participants (∼50%) reported an intention to use an e-therapy program for current or future eating problems, with intention ratings highest (70%) among those with probable bulimia nervosa (BN). Variables associated with an e-therapy preference were not currently receiving psychotherapy, more positive e-therapy attitudes, and greater stigma associated with professional help-seeking. Variables associated with e-therapy intentions were more positive e-therapy attitudes and a probable BN classification.

CONCLUSIONS

Present findings have important implications for increasing online intervention acceptance, engagement, and help-seeking among those at different stages of illness.

Prevention of eating disorders at universities: A systematic review and meta-analysis

BACKGROUND

Eating problems are highly prevalent among young adults. Universities could be an optimal setting to prevent the onset of eating disorders through psychological intervention. As part of the World Mental Health-International College Student initiative, this systematic review and meta-analysis synthesizes data on the efficacy of eating disorder prevention programs targeting university students.

METHOD

A systematic literature search of bibliographical databases (CENTRAL, MEDLINE, PsycINFO) for randomized trials comparing psychological preventive interventions for eating disorders targeting university students with psychoeducation or inactive controls was performed on October 22, 2019.

RESULTS

Twenty-seven studies were included. Thirteen (48.1%) were rated to have a low risk of bias. The relative risk of developing a subthreshold or full-blown eating disorder was incidence rate ratio = 0.62 (95% CI [0.44, 0.87], n _c = 8, numbers-needed-to-treat [NNT] = 26.08; standardized clinical interviews only), indicating a 38% decrease in incidence in the intervention groups compared to controls. Small to moderate between-group effects at posttest were found on eating disorder symptoms (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n _c = 26), dieting (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n _c = 21), body dissatisfaction (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n _c = 25), drive for thinness (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n _c = 12), weight concerns (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n _c = 13), and affective symptoms (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n _c = 18). The effects on bulimia nervosa symptoms were not significant. Heterogeneity was moderate across comparisons.

DISCUSSION

Eating disorder prevention on campus can have significant, small-to-moderate effects on eating disorder symptoms and risk factors. Results also suggest that the prevention of subthreshold and full-syndrome eating disorders is feasible using such interventions. More research is needed to identify ways to motivate students to use preventive eating disorder interventions.

ANTECEDENTES

Los trastornos de la conducta alimentaria son altamente prevalentes entre los adultos jóvenes. Las universidades podrían ser un entorno óptimo para prevenir la aparición de trastornos alimentarios a través de la intervención psicológica. Como parte de la iniciativa World Mental Health-International College Student, esta revisión sistemática y meta-análisis sintetiza datos sobre la eficacia de los programas de prevención de trastornos alimentarios dirigidos a estudiantes universitarios. MÉTODO: Una búsqueda bibliográfica sistemática de datos bibliográficas (CENTRAL, MEDLINE, PsycINFO) para ensayos aleatorios que comparaban intervenciones preventivas psicológicas para trastornos alimentarios dirigidos a estudiantes universitarios con psicoeducación o controles inactivos fue realizada hasta el 22 de octubre de 2019.

RESULTADOS

Se incluyeron 27 estudios. Trece (48,1%) fueron calificados como de bajo riesgo de sesgo. El riesgo relativo de desarrollar un trastorno de la conducta alimentaria subclínico (parcial) o completo fue IRR = 0.62 (95% CI [0.44, 0.87], n_c = 8, NNT = 26.08; sólo entrevistas clínicas estandarizadas), lo que indica una disminución del 38% en la incidencia en los grupos de intervención en comparación con los controles. Se encontraron efectos pequeños a moderados entre los grupos en la post-prueba en los síntomas del trastorno alimentario (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n_c = 26), dieta (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n_c = 21), insatisfacción corporal (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n_c = 25), impulso por delgadez (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n_c = 12), problemas de peso (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n_c = 13) y síntomas afectivos (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n_c = 18). Los efectos sobre los síntomas de la bulimia nervosa no fueron significativos. La heterogeneidad fue moderada en las comparaciones. DISCUSIÓN: La prevención de los trastornos de la conducta alimentaria en el campus universitario puede tener efectos significativos, de pequeños a moderados, sobre los síntomas del trastorno alimentario y los factores de riesgo. Los resultados también sugieren que la prevención de los trastornos alimentarios subclínicos o parciales y síndromes completos es factible utilizando tales intervenciones. Se necesita más investigación para identificar formas de motivar a los estudiantes a usar intervenciones preventivas para los trastornos de la conducta alimentaria.

Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Effectiveness of these delivery modalities through 4-year follow-up

OBJECTIVE

Independent trials have found that the dissonance-based Body Project eating disorder prevention program is efficacious and effective; the present trial provided the first test of whether delivery could be task-shifted from clinician-delivery to peer educator-delivery or Internet-delivery without loss of effectiveness through 4-year follow-up.

METHOD

Young women at high-risk for eating disorders because of body image concerns (N = 680, Mage = 22.2) recruited at 3 colleges were randomized to clinician-led Body Project groups, peer-led Body Project groups, the Internet-based eBody Project, or educational video control.

RESULTS

Participants in clinician- and peer-led Body Project groups and the eBody Project generally showed larger reductions in risk factors and eating disorder symptoms versus controls through 1- and 2-year follow-up (d = .16-.59), with some effects persisting through 3- and 4-year follow-ups (d = .28-.58). Peer-led Body Project participants showed greater reductions in some risk factors than eBody Project participants (d = .18-.19), but no other contrasts between Body Project interventions differed. Eating disorder onset over 4-year follow-up was significantly lower for peer-led Body Project participants (8.1%) than control participants (17.6%) and clinician-led Body Project participants (19.3%), and marginally lower than eBody Project participants (15.5%).

CONCLUSIONS

The evidence that all three Body Project interventions outperformed educational video controls, peer-led groups outperformed the Internet-based intervention, and peer-led groups showed lower eating disorder onset over 4-year follow-up than the other conditions are novel. Results imply that it might be optimal to task-shift Body Project delivery to peer-leaders to address implementation barriers associated with clinician-led delivery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Recruiting participants to an Internet-based eating disorder prevention trial: Impact of the recruitment strategy on symptom severity and program utilization

OBJECTIVE

Using data from a randomized controlled trial, we examined two different strategies to recruit participants for an indicated preventive intervention (StudentBodies-AN) for women at risk for anorexia nervosa and compared symptom severity and program utilization in participants recruited through each strategy.

METHOD

We recruited participants by announcing the study (a) in lectures at universities and handing out screening questionnaires (face-to-face recruitment) and (b) through different media channels, and the participants completed the screening questionnaire on our study website (media-based recruitment). We compared symptom severity and program utilization between the two groups.

RESULTS

A total of 4,646 women (face-to-face: 3,741, media-based: 905) were screened and 168 women (face-to-face: 114, media-based: 54) were randomized to the intervention. We found a statistically and clinically significant association between recruitment strategy and symptom severity: Participants who were recruited through media were more likely to fulfill the inclusion criteria (40.6% vs. 13.3%; p < .001) and endorsed significantly more frequently core behaviors and attitudes of disordered eating (EDE global score: 2.72 vs. 2.17, p < .05; Weight Concerns Scale [WCS] score: 66.05 vs. 56.40, p < .05) at baseline than participants recruited face-to-face. Also, participants recruited through media were more likely to log onto the program (χ² = 5.06; p = .029) and accessed more of the intervention.

DISCUSSION

Recruitment through media seems both more feasible and suitable to reach individuals in need of indicative prevention, and should be part of a multimodal recruitment package. Future studies should be explicitly designed to investigate the impact of recruitment modality on reach and effectiveness including cost-effectiveness analyses.

Adherence as a predictor of dropout in Internet-based guided self-help for adults with binge-eating disorder and overweight or obesity

OBJECTIVE

Internet-based guided self-help (GSH-I) is an efficacious treatment for adults with binge-eating disorder (BED) and overweight or obesity. Although broadly accessible, high dropout from GSH-I has been reported. However, little is known about the factors explaining dropout from GSH-I, including patients' adherence to treatment.

METHOD

Within a randomized trial on the treatment of BED, adherence to 4-month GSH-I was objectively assessed in N = 89 patients with BED and overweight or obesity. Objective adherence and subjective treatment evaluation were evaluated as predictors of dropout from GSH-I, defined as having accessed 5 or less of 11 modules. Cutoffs with optimal sensitivity and specificity were derived using Receiver Operating Characteristics curves analysis, and baseline sociodemographic and clinical correlates were determined.

RESULTS

According to our definition, n = 22 (24.7%) patients were defined as dropouts. Results of the full logistic regression model accounted for 72% of the variance in dropout and all objective adherence parameters (i.e., number of messages exchanged, days with a completed food diary, and days spent per module), but not patients' subjective GSH-I evaluation significantly predicted dropout. Specifically, not completing the food diary in week 7 had maximized sensitivity and specificity in predicting dropout. Patients' body mass index was positively associated with the number of messages exchanged between patients and coaches. No other associations between baseline variables and objective adherence were found.

DISCUSSION

Patients at risk for dropout from GSH-I can be reliably identified via monitoring of objective adherence and may be provided with additional interventions to prevent dropout.

Traumatic anticipation of childbirth and disordered eating during pregnancy

BACKGROUND

While research on Fear Of Childbirth (FOC) during pregnancy is on the rise, research regarding pretraumatic stress reactions is lacking. Moreover, less is known regarding negative anticipation of childbirth and Eating Disorders (ED). This study aims at identifying typologies of women in the prepartum period based on FOC and pretraumatic stress symptoms and investigating whether or not the identified profiles differ on levels of bulimic symptoms and Drive for Thinness (DT).

PARTICIPANTS AND METHODS

a sample of 213 pregnant women completed questionnaires assessing FOC, pretraumatic stress, DT and bulimic symptoms.

RESULTS

four clusters based on pretraumatic stress and FOC symptoms were identified: one characterised by traumatic symptoms, one showing moderated FOC symptoms, one with high symptomatology and one with low symptoms. Higher ED symptoms were found in women with both FOC and pretraumatic stress symptoms, and in the cluster showing elevated pretraumatic stress symptomatology.

CONCLUSIONS

To our knowledge, this is the first study focusing on anticipated traumatic reactions and ED in pregnant women. While some women evidenced FOC and pretraumatic stress symptoms, two different clusters, one with FOC and one with pretraumatic stress, were found. These findings suggest that, while sharing similarities, these constructs are different.

Evaluating reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adolescents: a systematic review

BACKGROUND

Past research has yielded promising results on the effectiveness of Internet-based interventions to prevent eating disorders (EDs) in adolescents, but further information is needed to evaluate the public health impact of their large-scale dissemination. This article used an established framework to systematically review the extent to which indicators of the reach, effectiveness, adoption, implementation and maintenance [cf. Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM)-framework] of universal and targeted online ED prevention programmes are reported in the literature, in order to estimate their future dissemination potential.

METHODS

The literature search was conducted on PubMed, Web of Science and PsycINFO, and complemented by searching existing reviews and the reference lists of the studies included. Twenty-two studies published between 2000 and April 2019 met the inclusion criteria. We extracted data on a total of 43 indicators, within RE-AIM dimensions for each article, including qualitative coding of fostering and hindering factors.

RESULTS

Reach (55.0%) and implementation (54.0%) were the dimensions reported on most frequently, followed by effectiveness (46.8%), adoption (34.7%) and maintenance (18.2%). While internal validity indicators were frequently reported (e.g. sample size, effects and intervention intensity), most studies failed to report on elements of external validity, such as representativeness of participants and settings, adoption rates, implementation costs and programme sustainability.

CONCLUSIONS

Evidence indicates that Internet-based ED prevention programmes can reach a large number of adolescents and can be feasibly implemented in school settings. However, given the paucity of large-scale dissemination studies available for review, the degree to which schools are willing to adopt preventive interventions, as well as the transferability of programmes to different settings and geographical regions remains unclear.