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

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.

Effectiveness of a Web-Based Cognitive Behavioral Self-Help Intervention for Binge Eating Disorder: A Randomized Clinical Trial

Importance

Binge eating disorder (BED) is one of the most frequent eating pathologies and imposes substantial emotional and physical distress, yet insufficient health care resources limit access to specialized treatment. Web-based self-help interventions emerge as a promising solution, offering more accessible care.

Objective

To examine the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with BED.

Design, Setting, and Participants

This 2-arm, parallel-group randomized clinical trial conducted from January 15, 2021, to August 3, 2022, in Germany and other German-speaking countries enrolled patients aged 18 to 65 years who met the diagnostic criteria for BED (according to the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]). Data analysis occurred between January 27 and September 4, 2023, following our statistical analysis plan.

Interventions

Participants were randomized to a web-based self-help intervention or a waiting-list control condition.

Main Outcomes and Measures

The primary outcome was a change in objective binge eating episodes from baseline to after treatment. Secondary outcomes included global eating pathology, clinical impairment, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation.

Results

A total of 1602 patients were screened, of whom 154 (mean [SD] age, 35.93 [10.59] years; 148 female [96.10%]) fulfilled the criteria for BED and were randomized (77 each to the intervention and control groups). The web-based intervention led to significant improvements in binge eating episodes (Cohen d, -0.79 [95% CI, -1.17 to -0.42]; P < .001), global eating psychopathology (Cohen d, -0.71 [95% CI, -1.07 to -0.35]; P < .001), weekly binge eating (Cohen d, -0.49 [95% CI, -0.74 to -0.24]; P < .001), clinical impairment (Cohen d, -0.75 [95% CI, -1.13 to -0.37]; P < .001), well-being (Cohen d, 0.38 [95% CI, 0.01 to 0.75]; P = .047), depression (Cohen d, -0.49 [95% CI, -0.86 to -0.12]; P = .01), anxiety (Cohen d, -0.37 [95% CI, -0.67 to -0.07]; P = .02), self-esteem (Cohen d, 0.36 [95% CI, 0.13 to 0.59]; P = .003), and emotion regulation (difficulties: Cohen d, -0.36 [95% CI, -0.65 to -0.07]; P = .01 and repertoire: Cohen d, 0.52 [95% CI, 0.19 to 0.84]; P = .003).

Conclusion and Relevance

In this randomized clinical trial of a web-based self-help intervention for patients with BED, the findings confirmed its effectiveness in reducing binge eating episodes and improving various mental health outcomes, highlighting a scalable solution to bridge the treatment gap for this condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT04876183.

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.

Mapping Treatment Advances in the Neurobiology of Binge Eating Disorder: A Concept Paper

Binge eating disorder (BED) is a complex and heritable mental health disorder, with genetic, neurobiological, neuroendocrinological, environmental and developmental factors all demonstrated to contribute to the aetiology of this illness. Although psychotherapy is the gold standard for treating BED, a significant subgroup of those treated do not recover. Neurobiological research highlights aberrances in neural regions associated with reward processing, emotion processing, self-regulation and executive function processes, which are clear therapeutic targets for future treatment frameworks. Evidence is emerging of the microbiota-gut-brain axis, which may mediate energy balance, high-lighting a possible underlying pathogenesis factor of BED, and provides a potential therapeutic strategy.

Binge-eating adolescent treatment (BEAT) - findings from a pilot study on effects and acceptance of a blended treatment program for youth with loss of control eating

BACKGROUND

Loss of Control Eating (LOC) is the most prevalent form of eating disorder pathology in youth, but research on evidence-based treatment in this group remains scarce. We assessed for the first time the effects and acceptance of a blended treatment program for youth between 14 and 24 years with LOC (Binge-eating Adolescent Treatment, BEAT).

METHODS

Twenty-four youths (mean age 19.1 years) participated in an active treatment of nine-weeks including three face-to-face workshops and six weekly email-guided self-help sessions, followed by four email guided follow-up sessions, one, three, six and 12 months after the active treatment. All patients completed a two-weeks waiting-time period before treatment begin (within-subject waitlist control design).

RESULTS

The number of weekly LOC episodes substantially decreased during both the waiting-time (effect size d = 0.45) and the active treatment (d = 1.01) period and remained stable during the subsequent 12-months follow-up (d = 0.20). The proportion of patients with full-threshold binge-eating disorder (BED) diagnoses decreased and transformed into LOC during the study course, while the abstainer rate of LOC increased. Values for depressive symptoms (d = 1.5), eating disorder pathology (d = 1.29) and appearance-based rejection sensitivity (d = 0.68) all improved on average from pretreatment to posttreatment and remained stable or further improved during follow-up (d between 0.11 and 0.85). Body weight in contrast remained constant within the same period. Treatment satisfaction among completers was high, but so was the dropout rate of 45.8% at the end of the 12-months follow-up.

CONCLUSIONS

This first blended treatment study BEAT might be well suited to decrease core symptoms of LOC, depressive symptoms and appearance-based rejection sensitivity. More research is needed to establish readily accessible interventions targeted more profoundly at age-salient maintaining factors such as appearance-based rejection sensitivity, while at the same time keeping dropout rates at a low level.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trials Register (ID: DRKS00014580; registration date: 21/06/2018).

Binge Eating (BE) and Obesity: Brain Activity and Psychological Measures before and after Roux-En-Y Gastric Bypass (RYGB)

Brain activity in response to food cues following Roux-En-Y Gastric Bypass (RYGB) in binge eating (BE) or non-binge eating (NB) individuals is understudied. Here, 15 RYGB (8 BE; 7 NB) and 13 no treatment (NT) (7 BE; 6 NB) women with obesity underwent fMRI imaging while viewing high and low energy density food (HEF and LEF, respectively) and non-food (NF) visual cues. A region of interest (ROI) analysis compared BE participants to NB participants in those undergoing RYGB surgery pre-surgery and 4 months post. Results were corrected for multiple comparisons using liberal (p < 0.006 uncorrected) and stringent (p < 0.05 FDR corrected) thresholds. Four months following RYGB (vs. no treatment (NT) control), both BE and NB participants showed greater reductions in blood oxygen level-dependent (BOLD) signals (a proxy of local brain activity) in the dorsomedial prefrontal cortex in response to HEF (vs. LEF) cues (p < 0.006). BE (vs. NB) participants showed greater increases in the precuneus (p < 0.006) and thalamic regions (p < 0.05 corrected) to food (vs. NF). For RYGB (vs. NT) participants, BE participants, but not NB participants, showed lower BOLD signal in the middle occipital gyrus (p < 0.006), whilst NB participants, but not BE participants, showed lower signal in inferior frontal gyrus (p < 0.006) in response to HEF (vs. LEF). Results suggest distinct neural mechanisms of RGYB in BE and may help lead to improved clinical treatments.

Psychological and Medical Treatments for Binge-Eating Disorder: A Research Update

Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 to November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.

Online multidisciplinary treatment of binge eating disorder in people with high weight: a case series study

BACKGROUND

Binge eating disorder (BED) is the most frequent eating behavior among the general population (Guerdjikova in Med Clin 103:669-680, 2019). Many studies on interventions and BED treatments have been carried out in the United States and Europe, few have been reported in Latin American populations. People with this disorder not only have physical consequences of it but also social and psychological ones, therefore a multidisciplinary treatment approach is a good option to treat this condition.

OBJECTIVE

To evaluate the feasibility of a multidisciplinary online intervention (i.e., psychological, nutritional, and physical activity) in patients with BED.

METHOD

The design was a case series study of two clinical treatment groups, with pre-test and post-test psychometric measures along with two follow-ups (at 2 and 6 months). Fifteen people diagnosed with BED (2 men and 13 women), with a mean age of 34.93 years (SD=11.91) and a mean initial BMI of 42, participated in this study. The treatment was carried out over the span of 28 sessions, each one being two hours per week consisting of 1 hour of group therapy and 1 hour of individual therapy. There were four evaluations: pre, post and two follow-ups.

RESULTS

Five patients did not complete the treatment (30%). The comparisons were made through the non-parametric Friedman test, finding a statistically significant decrease in binge eating symptoms (x2=15.57; p=.001), anxiety symptoms (x2=15.96; p=.001) and depression (x2=15.03; p=.002). There was an improvement in clarity (x2=11.60; p=.010) and emotional regulation (x2=7.75; p=.050), only in women. The patients reduced their body weight, and improved their eating and exercise habits by introducing fruits and vegetables and including 20-30 minutes of physical activity into their daily routine. Regarding the Objective Clinical Change Index, in terms of the objective clinical change, a positive change was observed in all the variables addressed.

CONCLUSIONS

The data presented allowed us to conclude that the online multidisciplinary intervention was effective in the treatment of BED. Trial registration Retrospectively registered.

Low intensity psychological interventions for the treatment of feeding and eating disorders: a systematic review and meta-analysis

BACKGROUND

Feeding and eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Low intensity psychological interventions have the potential to increase such access.

METHODS

A systematic review and meta-analysis were conducted on the use of low intensity psychological interventions for the treatment of feeding and eating disorders. Studies comparing low intensity psychological interventions against high intensity therapies and non-eating disorder specific psychological interventions were included, as well as those with waiting list control arms. There were three primary outcomes: eating disorder psychopathology, diagnostic and statistical manual of mental disorders (DSM) severity specifier-related outcomes and rates of remission/recovery.

RESULTS

Thirty-three studies met the inclusion criteria, comprising 3665 participants, and 30 studies were included in the meta-analysis. Compared to high intensity therapies, low intensity psychological interventions were equivalent on reducing eating disorder psychopathology (g = - 0.13), more effective at improving DSM severity specifier-related outcomes (g = - 0.15), but less likely to achieve remission/recovery (risk ratio (RR) = 0.70). Low intensity psychological interventions were superior to non-eating disorder specific psychological interventions and waiting list controls across all three primary outcomes.

CONCLUSION

Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms. Few potential moderators had a statistically significant effect on outcome. The number of studies for many comparisons was low and the methodological quality of the studies was poor, therefore results should be interpreted with caution. More research is needed to establish the effectiveness of low intensity psychological interventions for children and young people, as well as for individuals with anorexia nervosa, avoidant/restrictive food intake disorder, pica and rumination disorder.

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.

Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial

Background

In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptom reduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy (web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists.

Objective

This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients and therapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings; and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion.

Methods

A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eating disorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder not otherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping Alliance Questionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclass correlations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists. A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predicted eating disorder pathology and therapy completion.

Results

For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients and therapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreased significantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightly better after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatment were associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patient scores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulness scores of therapists were positively associated with treatment completion.

Conclusions

Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Of particular importance is patients’ confidence in their abilities as measured with the HAQ-Helpfulness subscale when predicting posttreatment eating disorder pathology and treatment completion.

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.

Integrating a web-based intervention into routine care of binge-eating disorder: Study protocol for a randomized controlled trial

Background

Although binge eating disorder (BED) is the most common eating pathology and carries a high mental and physical burden, access to specialized treatment is limited due to patient-related barriers and insufficient healthcare resources. Integrating web-based self-help programs into clinical care for BED may address this treatment gap by making evidence-based eating disorder interventions more accessible.

Methods

A two-armed randomized controlled trial will be conducted to evaluate the effectiveness of a web-based self-help intervention for BED in routine care settings. Patients aged 18-65 years fulfilling the diagnostic criteria for BED (N = 152) will be randomly allocated to (1) an intervention group receiving a 12-week web-based self-help program or (2) a waitlist control group with delayed access to the intervention. The primary outcome will be the number of binge eating episodes. Secondary outcomes include global eating pathology, functional impairments, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation abilities. Measurements will be conducted at baseline (study entrance), 6 weeks after baseline (mid-treatment), and 12 weeks after baseline (post-treatment). To capture outcomes and treatment mechanisms in real-time, traditional self-reports will be combined with weekly symptom monitoring and ecological momentary assessment.

Discussion

Evaluating the effectiveness of web-based interventions is essential to overcome the treatment gap for patients with BED. When adequately integrated into standard care, these programs have the potential to alleviate the high burden of BED for individuals, their families, and society.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT04876183, Identifier: NCT04876183 (registered on May 6th, 2021).