by Joye C. Anestis
On Tuesday, I began a discussion on alternative methods of treatment delivery. Today I want to continue that discussion by looking into online interventions for either the treatment or prevention of eating disorders (EDs). Well, I should say that initially I was going to write about both the prevention and treatment of EDs...but, as I looked for studies, I discovered that most of the literature covers preventative programs and very little research has been conducted on online interventions for individuals who already possess an ED. I find this state of affairs very interesting, and I'm not 100% sure why this is the case. Don't get me wrong, it is very exciting to find so much well-done research aimed at preventing such debilitating diseases, especially in a medium in which so many at-risk individuals can access it. But why not also have more programs for full-blown EDs? For disorders that are often accompanied by so much shame and secrecy, it seems that online interventions might be at least a good first step toward alleviating these symptoms (at least for bulimia and binge eating disorder). Especially when a number of self-help books exist to aid individuals suffering from these illnesses. I look forward to seeing more treatment literature in the future. Also, as I research alternative treatment delivery mechanisms for other mental disorders, I will be curious to see if this trend persists across disorders or if it is ED-specific.
Ok, enough of my tangent...on to some data!
Several studies have shown support for online interventions for eating disorder prevention in college-age women and adolescent girls (Zabinski et al, 2003). In fact, there is enough literature out there to make it impossible to sum all of them up in this one short article. So I will describe a sampling of studies below (and fully admit that this is not a comprehensive review...but I felt that these studies were an adequate representation of the overall literature. In the comments, please feel free to alert me to other articles that I didn't include). Take-home points from my general reading of this literature, though, is that a number of programs have shown promising results...and all the programs I came across are based on manualized, cognitive-behavioral treatments for EDs (i.e., they are modified from the reigning ESTs for bulimia and binge eating disorder).
- In 2006, Barr Taylor and colleagues hypothesized that they could prevent the development of EDs in a group of women who were at-risk for developing them. They recruited a large sample of at-risk women (the study took place in California). At-risk was defined as being a woman of college-age (the peak age of onset for EDs is 16-20) and having elevated weight and shape concerns, a well-researched risk factor for EDs. Since this was a prevention study, women who already met the diagnostic criteria for an ED were excluded (and referred to the appropriate therapy). In this study, the women were randomly assigned to either the treatment group or a control group (who got the opportunity to receive the intervention at the end of the follow-up period). The intervention, called Student Bodies (shown to be effective in other studies; Zabinski et al., 2003) was an 8-week, Internet-based, structured cognitive-behavioral program combined with an online, moderated discussion group. Each week, the participants logged in and were directed to updated program materials. They were expected to read the new materials and complete the corresponding assignments (e.g., the online discussion group, self-monitoring, writing journal entries). The discussion groups were moderated by a clinical psychologist or supervised graduate student. The investigators sent weekly e-mails to reinforce participation and encourage those who had failed to comply with some aspect of the program. Nine months after the end of the 8-week session, participants were notified by e-mail that the program would be available online for 2 weeks for them to review. Participant follow-up occurred at 1 and 2 years post-intervention. The results were very promising, leading to sustained reductions in weight and shape concerns, EDI - drive for thinness, EDI - bulimia, and the EDE questionnaire in college-age women at risk for developing EDs. The investigators also looked at the onset of EDs in their sample. Although they found no overall decrease in the onset of EDs (and no significant difference in the number of diagnoses between the 2 groups), they did find significant decreases in 2 subgroups of participants: those who had baseline compensatory behaviors (so they began the study already using laxatives, diuretics, vomiting, etc.) and those who had an elevated body mass index (BMI). Overall adherence to the program was high.
- Jacobi and colleagues (2007) reported results on a version of the Student Bodies program adapted for a German sample (e.g., materials were translated, materials considered too culture-specific were replaced). Again, participants were college-age women without the full-blown ED who wanted to improve their body image, and they were randomly assigned to either the treatment or control group. Results indicated that the intervention was effective in reducing weight and shape concerns and drive for thinness and increased knowledge about healthy eating, exercise, and eating disorders, especially in a sub-group identified as being at highest risk. These effects were maintained, and even improved, at a 3-month follow-up.
- Doyle et al. (2008) reported yet another adaptation of the Student Bodies protocol. This adaptation, coined Student Bodies 2 (SB2), is a 16-week, internet-delivered, cognitive-behavioral program designed to help overweight adolescents lose weight and increase positive body image. Participants were overweight adolescent males & females (yes, males get EDs too!) aged 12-17 years, and they were randomized to either the treatment or usual care (received handouts containing basic info on nutrition and physical activity, told to continue visiting their physicians as needed, offered access to the internet program at 4-month follow-up). Assessments were done at baseline, post-treatment, and 4-month follow-up. The main outcomes investigated here were weight loss and eating disorder symptoms. The results indicated that the treatment group lost significantly more weight than the control group at post-treatment, but the loss was not maintained at follow-up. Results on self-report measures were inconclusive. I find it interesting that this was the least supportive article I found and also the only one using a mixed-sex sample. The authors did not conduct analyses by sex to determine if sex differences were present.
- Paxton and colleagues (2007) randomly assigned adult women with high body dissatisfaction to face-to-face treatment, internet delivered treatment, or a delayed treatment control group. The intervention in this study was an 8-week manualized CBT intervention called Set Your Body Free. The same intervention was delivered to both treatment groups. The face-to-face group met weekly for group sessions; the internet group logged on weekly to a secure, password-protected chat room. Groups were assessed at baseline, 8-9 weeks later, and then at 6-month follow-up. The results indicated that both treatment groups improved in regard to body dissatisfaction, the primary outcome, and these improvements were maintained at follow-up. Interestingly, post-treatment improvements were the greatest in the group that received the face-to-face intervention.
- Heinicke et al. (2007) examined an adaptation of Set Your Body Free for adolescent girls (renamed My Body, My Life). Subjects were high school girls, ages 12-18, who self-identified as having body image or eating problems. They were randomly assigned to the intervention or to a delayed treatment control group. The authors report clinically significant improvements in multiple domains, including body dissatisfaction, disordered eating, and depression for the intervention group. These improvements were found at post-treatment and maintained at follow-up (2 & 6-months)
- For an interesting meditation on using e-mailing as an adjunct to in-person treatment with clients with EDs, see Joel Yager's article in Volume 54(12) of Psychiatric Services.
If you are interested in learning more about the treatment of eating disorders, we recommend the following resources, all of which are available through our online store:
- Overcoming Binge Eating
- Binge Eating: Nature, Assessment, and Treatment
- Cognitive Behavior Therapy and Eating Disorders
- Crave: Why You Binge Eat and How to Stop
- Dialectical Behavior Therapy for Binge Eating and Bulimia
- Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
Subscribe in a reader
