@Article{info:doi/10.2196/68846, author="Thomas, Carien Pamela and Bark, Pippa and Rowe, Sarah", title="Exploring Therapists' Approaches to Treating Eating Disorders to Inform User-Centric App Design: Web-Based Interview Study", journal="JMIR Form Res", year="2025", month="May", day="6", volume="9", pages="e68846", keywords="eating disorders", keywords="binge eating", keywords="bulimia", keywords="anorexia", keywords="qualitative research", keywords="mental health", keywords="smartphone apps", keywords="digital interventions", keywords="eHealth", keywords="mobile health", keywords="artificial intelligence", abstract="Background: The potential for digital interventions in self-management and treatment of mild to moderate eating disorders (EDs) has already been established. However, apps are infrequently recommended by ED therapists to their clients. Those that are recommended often have poor engagement and user satisfaction, leading to unsatisfactory outcomes. Barriers to recommendation include patient safety, data privacy, and a perception that they may not be effective. Many existing interventions have limited functionality or do not differ much from manual cognitive behavioral therapy (CBT) or self-help books, which may not adequately support the therapeutic process or sustain user engagement. Objective: This study aims to explore the perspectives of therapists who support people with mild to moderate EDs in the community, exploring their existing treatment approach and how an ED app might fit in the treatment pathway alongside treatment. Methods: Semistructured web-based interviews were completed with ED therapists in the United Kingdom. Participants were recruited from First Steps ED, a specialist community-based ED service, and Thrive Mental Wellbeing, a workplace mental health provider. Five main themes were covered: (1) therapists' treatment approach, (2) how therapy was implemented in practice, (3) strategies for engaging and motivating clients, (4) perspectives on a potential ED app, and (5) suggestions for app content and design. A structured thematic analysis was validated by 2 researchers. Results: Overall, 12 ED and mental health therapists (mean age 28.7, SD 7.3 y; female therapists: n=7, 58\%; male therapists: n=5, 42\%) participated. Therapists dealing with complex ED issues went beyond traditional CBT using additional therapeutic techniques and a flexible, person-centered approach to treatment. This included engagement and motivational strategies to support the client, elements of which could be mirrored in an app. Therapists identified the therapeutic relationship as key to success, which might have been hard to replicate in an app. They saw the potential for evidence-based apps across all stages of the treatment pathway. The need to address safeguarding, data privacy, and the potential for triggering content within the app was vital. Conclusions: This study advanced our understanding of how to design and develop clinically safe, evidence-based ED apps that can complement therapy by extending the continuity of care and the self-management and psychoeducation of clients. It emphasized integrative, adaptive CBT that incorporated other therapeutic approaches based on individuals' needs, which could be replicated in an app, as could the strategies to support engagement and motivation. It gave a cautious yet optimistic perspective on the potential integration of apps into ED treatment across all stages of the treatment pathway, from pretreatment maintenance to posttreatment maintenance. It highlighted various concerns that could be addressed and potential limitations, such as the therapeutic relationship, while recognizing the growing potential of apps with rapid technology and artificial intelligence advancements. ", doi="10.2196/68846", url="https://formative.jmir.org/2025/1/e68846" } @Article{info:doi/10.2196/66465, author="Blalock, V. Dan and Mehler, S. Philip and Michel, M. Deborah and Duffy, Alan and Le Grange, Daniel and O'Melia, M. Anne and Rienecke, D. Renee", title="Virtual Versus In-Person Intensive Outpatient Treatment for Eating Disorders During the COVID-19 Pandemic in United States--Based Treatment Facilities: Naturalistic Study", journal="J Med Internet Res", year="2025", month="May", day="2", volume="27", pages="e66465", keywords="eating disorders", keywords="virtual care", keywords="intensive outpatient", keywords="COVID-19", keywords="higher level of care", keywords="depression", keywords="suicidal ideation", keywords="treatment", keywords="access", keywords="naturalistic", abstract="Background: While virtual therapy has proven effective in treating eating disorders (EDs), little work has examined virtual therapy at higher levels of care, which are treatment options providing more support than weekly outpatient therapy including intensive outpatient (IOP) treatment. Objective: This study aimed to add to the limited research on in-person versus virtual treatment at a higher level of care by comparing treatment outcomes between an in-person IOP and a virtual IOP (VIOP) for patients with EDs. We hypothesized that there would be no differences in improvements between VIOP and in-person IOP groups. Methods: This study has a nonrandomized multiple cohort design. Patients with EDs receiving treatment who completed both admission and discharge questionnaires in VIOP treatment (n=231) and in-person IOP treatment (n=39) between 2021 and mid-2022 within a large ED health care system in the United States were included. The Eating Disorder Examination--Questionnaire (EDE-Q) was used to measure ED symptoms. The Patient Health Questionnaire-9 (PHQ-9) was used to measure depression, and item 9 of the PHQ-9 was used to measure suicidal ideation. Welch t tests on admission, discharge, and raw change scores were conducted. Logistic regressions were conducted predicting treatment program (reference group VIOP vs in-person IOP) from the residualized change in each outcome and were adjusted for all significantly different factors between groups. Results: VIOP patients were significantly older (mean 28.03, SD 11.09) than in-person IOP patients (mean 19.51, SD 6.98) and displayed significantly different numbers of ED diagnoses and more comorbid psychiatric diagnoses (VIOP: mean 1.23, SD 1.12; in-person IOP: mean 0.33, SD 0.84) but no differences in race (VIOP: 175/231, 75.6\% White; in-person IOP: 30/39, 76.9\% White), gender (VIOP: 196/231, 84.8\% female; in-person IOP: 35/39, 89.7\% female), or length of stay (VIOP: mean 58.84, SD 26.69; in-person IOP: mean 57.33, SD 19.67). When compared to in-person IOP patients, controlling for age, diagnosis, number of comorbid diagnoses, and admission scores, VIOP patients did not exhibit significantly different improvements in ED symptom scores (EDE-Q Global: b=0.01, SE 0.18, t=0.04, odds ratio [OR] 1.01, 95\% CI 0.71-1.43; P=.97). However, VIOP patients exhibited significantly greater improvements in depression scores (PHQ-9: b=--0.14, SE 0.05, t230=--2.85, OR 0.87, 95\% CI 0.79-0.96; P=.004) and the PHQ-9 suicidal ideation item (PHQ-9 item 9: b=--0.72, SE 0.34, t230=--2.13, OR 0.49, 95\% CI 0.25-0.93; P=.03). Conclusions: ED outcomes were similar for VIOP and in-person IOP patients. Contrary to our hypotheses, depression and suicidal ideation outcomes improved more for VIOP patients than for in-person IOP patients. Furthermore, treatment access for non-White and older adults does not appear descriptively worse for VIOP treatment compared to in-person IOP treatment, though these trends should be further explored. VIOP treatment may improve treatment access in an equitable fashion without reducing treatment quality. ", doi="10.2196/66465", url="https://www.jmir.org/2025/1/e66465", url="http://www.ncbi.nlm.nih.gov/pubmed/40314999" } @Article{info:doi/10.2196/66298, author="Halicki-Asakawa, Aman{\'e} and Mocci, Julia and Libben, Maya", title="Mobile App--Delivered Motivational Interviewing for Women on Eating Disorder Treatment Waitlists (MI-Coach: ED): Protocol for an App Development and Pilot Evaluation", journal="JMIR Res Protoc", year="2025", month="Apr", day="10", volume="14", pages="e66298", keywords="eating disorders", keywords="motivational interviewing", keywords="treatment barriers", keywords="digital interventions", keywords="pilot test", keywords="protocol", keywords="eating disorder", keywords="eating", keywords="woman", keywords="women", keywords="female", keywords="Canada", keywords="Canadian", keywords="mobile apps", keywords="mobile health", keywords="mHealth", keywords="app development", keywords="app-based", keywords="mental health", keywords="pilot evaluation", keywords="waitlists", keywords="mixed methods", keywords="feasibility", keywords="acceptability", keywords="service delivery", abstract="Background: A significant increase in eating disorder (ED) service waitlists has been observed in the past several years, exacerbating existing barriers to care (eg, long waitlists, scarcity of treatment centers, and positive beliefs surrounding pathology). Given that treatment delays have important clinical correlates (eg, entrenchment of ED pathology), exploring new methods of mental health service delivery for this population is of critical concern. App-based motivational interviewing (MI) delivered prior to the start of treatment has the potential to improve accessibility by simultaneously addressing structural (eg, travel costs) and individual (eg, low motivation) barriers to care. Despite the potential benefits, there remains a lack of empirically validated, ED-specific MI-based mobile apps. Evaluating the feasibility and acceptability of such interventions is a crucial first step before progressing to full-scale efficacy trials. Objective: This multiphasic mixed methods study aims to develop and assess the feasibility and acceptability of MI-Coach: ED, a novel app designed to increase motivation among women waitlisted for ED treatment. Specifically, this study seeks to determine participant engagement levels, user satisfaction, and perceived usability of the app, as well as to explore preliminary trends in motivation and ED-related symptoms following app use. Methods: Phase I adapted the content and interface of an existing app based on evidence-based principles (MI-Coach) for an ED population. Phase II pilot tested the app through a pre-post evaluation. Participants (n=30) aged 18 years and older were recruited from ED treatment waitlists in British Columbia, Canada. After completing baseline assessments evaluating demographic and clinical variables (eg, motivation, eating pathology, depression, and anxiety symptoms), participants were provided access to MI-Coach: ED for 1 month. Participants completed postintervention assessments and provided both quantitative and qualitative feedback on the app. Feasibility will be evaluated through the total number of participants recruited, study dropout rates, and engagement indicators (eg, modules completed) within the app. Acceptability will be assessed through self-report measures and semistructured exit interviews, which will explore user experiences, perceived benefits, and barriers to app engagement. Additionally, exploratory analyses will examine changes in motivation and ED symptoms before and after the intervention. Results: The MI-Coach: ED app has been developed, and recruitment was initiated in November 2022 and terminated in May 2024. Results are being analyzed and will be submitted for publication in May 2025. Conclusions: This study has the potential to transform ED service delivery and mitigate the impacts of existing treatment barriers for this population. By leveraging a digital MI-based intervention, MI-Coach: ED could serve as a scalable and accessible pretreatment tool, helping to bridge the gap between initial help-seeking and formal ED treatment. Findings from this study will inform the refinement of the intervention and recruitment strategies for future large-scale efficacy trials. International Registered Report Identifier (IRRID): DERR1-10.2196/66298 ", doi="10.2196/66298", url="https://www.researchprotocols.org/2025/1/e66298" } @Article{info:doi/10.2196/66554, author="Keel, K. Pamela and Bodell, P. Lindsay and Ali, I. Sarrah and Starkey, Austin and Trotta, Jenna and Luxama, Woody J. and Halfhide, Chlo{\'e} and Hill, G. Naomi and Appelbaum, Jonathan and Williams, L. Diana", title="Examining Weight Suppression, Leptin Levels, Glucagon-Like Peptide 1 Response, and Reward-Related Constructs in Severity and Maintenance of Bulimic Syndromes: Protocol and Sample Characteristics for a Cross-Sectional and Longitudinal Study", journal="JMIR Res Protoc", year="2025", month="Apr", day="8", volume="14", pages="e66554", keywords="binge eating", keywords="weight suppression", keywords="leptin", keywords="glucagon-like peptide 1", keywords="insulin", keywords="reward", keywords="satiation", keywords="longitudinal", keywords="behavior", keywords="Research Domain Criteria", abstract="Background: Bulimia nervosa and related syndromes (BN-S) characterized by binge eating vary considerably in illness severity and course. Using the Research Domain Criteria framework of the National Institute of Mental Health, we developed a model positing that the same set of physiological consequences of weight suppression (WS; defined as the difference between the highest and current adult body weight) contribute to binge-eating severity and maintenance by (1) increasing the drive or motivation to consume food (reward valuation effort [RVE]) and (2) decreasing the ability for food consumption to lead to a state of satiation or satisfaction (reward satiation). Objective: Our funded project aimed to test concurrent associations among WS, physiological factors (leptin concentrations and postprandial glucagon-like peptide 1 [GLP-1] response), behavioral indicators of RVE (breakpoint on progressive ratio tasks) and reward satiation (ad-lib test meal intake), self-report of these core constructs, and binge-eating severity in BN-S (aim 1); test prospective associations to determine whether WS predicts BN-S maintenance in longitudinal models and whether posited mediators also predict BN-S maintenance (aim 2); and determine whether associations between WS and BN-S severity and maintenance are mediated by alterations in leptin levels, GLP-1 response, RVE, and reward satiation (aim 3). Methods: We aimed to recruit a sample of 320 women with BN-S or noneating disorder controls, with BMI from 16 kg/m2 to 35 kg/m2, for our study. The study included diagnostic interviews; questionnaires; height, weight, and percentage of body fat measurements; weight history; fasting leptin level; postprandial GLP-1 and insulin responses to a fixed meal; and ad-lib meal and progressive ratio tasks to behaviorally measure reward satiation and RVE, respectively, at baseline, with at least 78.1\% (250/320) of the participants providing data at 6- and 12-month follow-up visits. Data will be analyzed using structural equation models to test posited pathways. Results: Data collection began in November 2016 and ended in April 2023, pausing in-person data collection from March 2020 to February 2021 due to the COVID-19 pandemic. Of 399 eligible women enrolled, 290 (72.7\%) provided clinical, behavioral, and biological data at baseline, and 249 (62.4\%) provided follow-up data. Measures demonstrated strong psychometric properties. Conclusions: We seek to identify biobehavioral predictors to inform treatments that target key factors influencing the severity and course of binge eating. These data, supported solely through federal funding, can inform questions emerging from recent interest and controversy surrounding the use of GLP-1 agonists for binge eating. International Registered Report Identifier (IRRID): RR1-10.2196/66554 ", doi="10.2196/66554", url="https://www.researchprotocols.org/2025/1/e66554" } @Article{info:doi/10.2196/56147, author="Wang, Xiao and Xiao, Yuxue and Nam, Sujin and Zhong, Ting and Tang, Dongyan and Li, Cheung William Ho and Song, Peige and Xia, Wei", title="Use of Mukbang in Health Promotion: Scoping Review", journal="J Med Internet Res", year="2025", month="Mar", day="27", volume="27", pages="e56147", keywords="mukbang", keywords="health promotion", keywords="eating behaviors", keywords="appetite", keywords="scoping review", abstract="Background: Mukbang is a recent internet phenomenon in which anchors publicly record and show their eating through short video platforms. Researchers reported a tangible impact of mukbang on the psychological and physical health, appetite, and eating behavior of the public, it is critical to obtain clear and comprehensive insights concerning the use of mukbang to promote the viewers' appetite, eating behaviors, and health to identify directions for future work. Objective: This scoping review aims to comprehensively outline the current evidence regarding the impact of mukbang consumption on dietary behaviors, appetite regulation, flavor perception, and physical and psychological well-being. Specifically, we conducted an analysis of public perceptions and attitudes toward mukbang while summarizing the reciprocal influence it has on health promotion. Methods: This study was conducted as a scoping review following the Joanna Briggs Institute guideline and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. We comprehensively searched 8 electronic databases in Chinese, English, and Korean languages. We also searched gray literature sources like Google Scholar and ProQuest. We used a data extraction chart to extract information relevant to the impact of mukbang on health. The extracted data were qualitatively analyzed to form different themes related to health, categorizing and integrating the results based on the type of study (qualitative, observational, and experimental). Results: This scoping review finally included 53 studies; the annual distribution exhibited a consistent upward trend across all categories since their initial publication in 2017. Based on the results of the analysis, we have summarized 4 themes, which showed that mukbang may have positive effects on viewers' appetite, food choices, and weight control; it can also meet the psychological needs of viewers and provide digital companionship and happiness. However, excessive viewing may also be harmful to viewer's health, which has also caused health concerns for some viewers. Conclusions: This study conducted a comprehensive search, screening, and synthesis of existing studies focusing on mukbang and health across various languages and varying levels of quality, which has presented the analytical evidence of the relationship between mukbang and dietary behaviors, appetite, flavor perception, and health. According to the results, future research could consider analyzing the beneficial and harmful factors of mukbang, thereby further optimizing the existing mukbang videos accordingly to explore the potential of using mukbang for health intervention or promotion, so as to improve or customize the content of mukbang based on this scoping review, maximize the appetite and health promotion effects of mukbang videos. Trial Registration: INPLASY INPLASY2022120109; https://inplasy.com/inplasy-2022-12-0109/ ", doi="10.2196/56147", url="https://www.jmir.org/2025/1/e56147" } @Article{info:doi/10.2196/59691, author="Rooper, R. Isabel and Ortega, Adrian and Massion, A. Thomas and Lakhtakia, Tanvi and Kruger, Macarena and Parsons, M. Leah and Lipman, D. Lindsay and Azubuike, Chidiebere and Tack, Emily and Obleada, T. Katrina and Graham, K. Andrea", title="Optimizing Testimonials for Behavior Change in a Digital Intervention for Binge Eating: Human-Centered Design Study", journal="JMIR Form Res", year="2025", month="Mar", day="21", volume="9", pages="e59691", keywords="health behavior", keywords="health narratives", keywords="binge eating", keywords="user engagement", keywords="personalization", keywords="behavior change", keywords="digital health", keywords="intervention", keywords="human-centered design", keywords="behavioral health", keywords="preferences", abstract="Background: Testimonials from credible sources are an evidence-based strategy for behavior change. Behavioral health interventions have used testimonials to promote health behaviors (eg, physical activity and healthy eating). Integrating testimonials into eating disorder (ED) interventions poses a nuanced challenge because ED testimonials can promote ED behaviors. Testimonials in ED interventions must therefore be designed carefully. Some optimal design elements of testimonials are known, but questions remain about testimonial speakers, messaging, and delivery, especially for ED interventions. Objective: We sought to learn how to design and deliver testimonials focused on positive behavior change strategies within our multisession digital binge eating intervention. Methods: We applied human-centered design methods to learn users' preferences for testimonial speakers, messaging, and delivery (modalities, over time, and as ``nudges'' for selecting positive behavior change strategies they could practice). We recruited target users of our multisession intervention to complete design sessions. Adults (N=22, 64\% self-identified as female; 32\% as non-Hispanic Black, 41\% as non-Hispanic White, and 27\% as Hispanic) with recurrent binge eating and obesity completed individual interviews. Data were analyzed using methods from thematic analysis. Results: Most participants preferred designs with testimonials (vs without) for their motivation and validation of the intervention's efficacy. A few distrusted testimonials for appearing too ``commercial'' or personally irrelevant. For speakers, participants preferred sociodemographically tailored testimonials and were willing to report personal data in the intervention to facilitate tailoring. For messaging, some preferred testimonials with ``how-to'' advice, whereas others preferred ``big picture'' success stories. For delivery interface, participants were interested in text, video, and multimedia testimonials. For delivery over time, participants preferred testimonials from new speakers to promote engagement. When the intervention allowed users to choose between actions (eg, behavioral strategies), participants preferred testimonials to be available across all actions but said that selectively delivering a testimonial with one action could ``nudge'' them to select it. Conclusions: Results indicated that intervention users were interested in testimonials. While participants preferred sociodemographically tailored testimonials, they said different characteristics mattered to them, indicating that interventions should assess users' most pertinent identities and tailor testimonials accordingly. Likewise, users' divided preferences for testimonial messaging (ie, ``big picture'' vs ``how-to'') suggest that optimal messaging may differ by user. To improve the credibility of testimonials, which some participants distrusted, interventions could invite current users to submit testimonials for future integration in the intervention. Aligned with nudge theory, our findings indicate testimonials could be used as ``nudges'' within interventions---a ripe area for further inquiry---though future work should test if delivering a testimonial only with the nudged choice improves its uptake. Further research is needed to validate these design ideas in practice, including evaluating their impact on behavior change toward improving ED behaviors. ", doi="10.2196/59691", url="https://formative.jmir.org/2025/1/e59691" } @Article{info:doi/10.2196/57986, author="Schnepper, Rebekka and Roemmel, Noa and Schaefert, Rainer and Lambrecht-Walzinger, Lena and Meinlschmidt, Gunther", title="Exploring Biases of Large Language Models in the Field of Mental Health: Comparative Questionnaire Study of the Effect of Gender and Sexual Orientation in Anorexia Nervosa and Bulimia Nervosa Case Vignettes", journal="JMIR Ment Health", year="2025", month="Mar", day="20", volume="12", pages="e57986", keywords="anorexia nervosa", keywords="artificial intelligence", keywords="bulimia nervosa", keywords="ChatGPT", keywords="eating disorders", keywords="LLM", keywords="responsible AI", keywords="transformer", keywords="bias", keywords="large language model", keywords="gender", keywords="vignette", keywords="quality of life", keywords="symptomatology", keywords="questionnaire", keywords="generative AI", keywords="mental health", keywords="AI", abstract="Background: Large language models (LLMs) are increasingly used in mental health, showing promise in assessing disorders. However, concerns exist regarding their accuracy, reliability, and fairness. Societal biases and underrepresentation of certain populations may impact LLMs. Because LLMs are already used for clinical practice, including decision support, it is important to investigate potential biases to ensure a responsible use of LLMs. Anorexia nervosa (AN) and bulimia nervosa (BN) show a lifetime prevalence of 1\%?2\%, affecting more women than men. Among men, homosexual men face a higher risk of eating disorders (EDs) than heterosexual men. However, men are underrepresented in ED research, and studies on gender, sexual orientation, and their impact on AN and BN prevalence, symptoms, and treatment outcomes remain limited. Objectives: We aimed to estimate the presence and size of bias related to gender and sexual orientation produced by a common LLM as well as a smaller LLM specifically trained for mental health analyses, exemplified in the context of ED symptomatology and health-related quality of life (HRQoL) of patients with AN or BN. Methods: We extracted 30 case vignettes (22 AN and 8 BN) from scientific papers. We adapted each vignette to create 4 versions, describing a female versus male patient living with their female versus male partner (2 {\texttimes} 2 design), yielding 120 vignettes. We then fed each vignette into ChatGPT-4 and to ``MentaLLaMA'' based on the Large Language Model Meta AI (LLaMA) architecture thrice with the instruction to evaluate them by providing responses to 2 psychometric instruments, the RAND-36 questionnaire assessing HRQoL and the eating disorder examination questionnaire. With the resulting LLM-generated scores, we calculated multilevel models with a random intercept for gender and sexual orientation (accounting for within-vignette variance), nested in vignettes (accounting for between-vignette variance). Results: In ChatGPT-4, the multilevel model with 360 observations indicated a significant association with gender for the RAND-36 mental composite summary (conditional means: 12.8 for male and 15.1 for female cases; 95\% CI of the effect --6.15 to ?0.35; P=.04) but neither with sexual orientation (P=.71) nor with an interaction effect (P=.37). We found no indications for main effects of gender (conditional means: 5.65 for male and 5.61 for female cases; 95\% CI --0.10 to 0.14; P=.88), sexual orientation (conditional means: 5.63 for heterosexual and 5.62 for homosexual cases; 95\% CI --0.14 to 0.09; P=.67), or for an interaction effect (P=.61, 95\% CI --0.11 to 0.19) for the eating disorder examination questionnaire overall score (conditional means 5.59?5.65 95\% CIs 5.45 to 5.7). MentaLLaMA did not yield reliable results. Conclusions: LLM-generated mental HRQoL estimates for AN and BN case vignettes may be biased by gender, with male cases scoring lower despite no real-world evidence supporting this pattern. This highlights the risk of bias in generative artificial intelligence in the field of mental health. Understanding and mitigating biases related to gender and other factors, such as ethnicity, and socioeconomic status are crucial for responsible use in diagnostics and treatment recommendations. ", doi="10.2196/57986", url="https://mental.jmir.org/2025/1/e57986" } @Article{info:doi/10.2196/60844, author="Gulec, Hayriye and Muzik, Michal and Smahel, David and Dedkova, Lenka", title="Longitudinal Associations Between Adolescents' mHealth App Use, Body Dissatisfaction, and Physical Self-Worth: Random Intercept Cross-Lagged Panel Study", journal="JMIR Ment Health", year="2025", month="Mar", day="11", volume="12", pages="e60844", keywords="mHealth app", keywords="body dissatisfaction", keywords="physical self-worth", keywords="random intercept cross-lagged panel model", keywords="RI-CLPM", keywords="longitudinal study", keywords="adolescent", abstract="Background: Longitudinal investigation of the association between mobile health (mHealth) app use and attitudes toward one's body during adolescence is scarce. mHealth apps might shape adolescents' body image perceptions by influencing their attitudes toward their bodies. Adolescents might also use mHealth apps based on how they feel and think about their bodies. Objective: This prospective study examined the longitudinal within-person associations between mHealth app use, body dissatisfaction, and physical self-worth during adolescence. Methods: The data were gathered from a nationally representative sample of Czech adolescents aged between 11 and 16 years (N=2500; n=1250, 50\% girls; mean age 13.43, SD 1.69 years) in 3 waves with 6-month intervals. Participants completed online questionnaires assessing their mHealth app use, physical self-worth, and body dissatisfaction at each wave. The mHealth app use was determined by the frequency of using sports, weight management, and nutritional intake apps. Physical self-worth was assessed using the physical self-worth subscale of the Physical Self Inventory-Short Form. Body dissatisfaction was measured with the items from the body dissatisfaction subscale of the Eating Disorder Inventory-3. The random intercept cross-lagged panel model examined longitudinal within-person associations between the variables. A multigroup design was used to compare genders. Due to the missing values, the final analyses used data from 2232 adolescents (n=1089, 48.8\% girls; mean age 13.43, SD 1.69 years). Results: The results revealed a positive within-person effect of mHealth app use on the physical self-worth of girls: increased mHealth app use predicted higher physical self-worth 6 months later ($\beta$=.199, P=.04). However, this effect was not consistent from the 6th to the 12th month: a within-person increase in using apps in the 6th month did not predict changes in girls' physical self-worth in the 12th month ($\beta$=.161, P=.07). Regardless of gender, the within-person changes in the frequency of using apps did not influence adolescents' body dissatisfaction. In addition, neither body dissatisfaction nor physical self-worth predicted app use frequency at the within-person level. Conclusions: This study highlighted that within-person changes in using mHealth apps were differentially associated with adolescents' body-related attitudes. While increased use of mHealth apps did not influence body dissatisfaction across genders, it significantly predicted higher physical self-worth in adolescent girls 6 months later. A similar association was not observed among boys after 6 months. These findings indicate that using mHealth apps is unlikely to have a detrimental impact on adolescents' body dissatisfaction and physical self-worth; instead, they may have a positive influence, particularly in boosting the physical self-worth of adolescent girls. ", doi="10.2196/60844", url="https://mental.jmir.org/2025/1/e60844" } @Article{info:doi/10.2196/70278, author="Miranda, Christina and Matheson, Brittany and Datta, Nandini and Whyte, Aileen and Yang, Hyun-Joon and Schmiedmayer, Paul and Ravi, Vishnu and Aalami, Oliver and Lock, James", title="Enhancing Distress Tolerance Skills in Adolescents With Anorexia Nervosa Through the BALANCE Mobile App: Feasibility and Acceptability Study", journal="JMIR Form Res", year="2025", month="Feb", day="28", volume="9", pages="e70278", keywords="mHealth", keywords="mobile health", keywords="mobile application", keywords="emotion regulation", keywords="eating disorders", keywords="family-based treatment", keywords="distress tolerance", keywords="mealtimes", abstract="Background: Anorexia nervosa is a severe psychiatric disorder with high morbidity and mortality, particularly among adolescents. Family-based treatment (FBT) is the leading evidence-based intervention for adolescent anorexia nervosa, involving parents in renourishment and behavior interruption. Despite its effectiveness, challenges in distress tolerance and emotion regulation during high-stress situations, such as mealtimes, contribute to suboptimal treatment outcomes, with only 35\% to 50\% of adolescents achieving full recovery. Enhancing distress tolerance skills during FBT may improve treatment responses and recovery rates. The BALANCE mobile app was developed to address this need, offering real-time, dialectical behavior therapy (DBT)--based distress tolerance skills to support adolescents and families during mealtimes. Objective: Our aim was to explore the feasibility and acceptability of a mobile app designed to deliver distress tolerance skills to adolescents with and adolescents without anorexia nervosa. When fully programmed and optimized, we plan to use the mobile app to improve distress tolerance during mealtimes for adolescents with anorexia nervosa undergoing FBT. Methods: BALANCE was developed collaboratively with Stanford University's Center for Biodesign, leveraging the expertise of clinical psychologists and using biodesign student input and the Stanford Spezi ecosystem. The app underwent an iterative development process, with feedback from adolescent users. The initial feasibility and acceptability of the app were assessed through self-reported questionnaires and structured interviews with 24 adolescents aged 12 to 18 years, including 4 diagnosed with anorexia nervosa and 20 healthy controls. Adolescents with anorexia nervosa specifically used the app during mealtimes, and healthy controls used it as needed. Participants assessed the app's usability, perceived effectiveness, and its impact on their distress tolerance. Results: The app demonstrated high usability and acceptability. Of 24 participants, 83\% (n=20) reported enjoying the app, 88\% (n=21) would recommend it to peers, and 100\% (n=24) found it user-friendly. Adolescents with anorexia nervosa reported that BALANCE helped them manage stressful mealtimes more effectively, highlighting features such as guided meditation, breathing exercises, and gamification elements as particularly effective. Healthy controls provided additional feedback, confirming the app's broad appeal to the target audience and potential scalability. Preliminary findings suggest that BALANCE may enhance distress tolerance in adolescents with and adolescents without anorexia nervosa. Conclusions: BALANCE shows promise as an innovative mobile health intervention for enhancing distress tolerance in adolescents with anorexia nervosa. Its user-friendly design and tailored DBT-based skills make it a feasible tool for integration into FBT. Future research should explore its integration into clinical practice and its impact on treatment outcomes. As distress tolerance skills are relevant to a range of mental health conditions, future research may also expand BALANCE's application to broader adolescent populations. ", doi="10.2196/70278", url="https://formative.jmir.org/2025/1/e70278" } @Article{info:doi/10.2196/57795, author="Cheung, Gar-Mun Lauryn and Thomas, Carien Pamela and Brvar, Eva and Rowe, Sarah", title="User Experiences of and Preferences for Self-Guided Digital Interventions for the Treatment of Mild to Moderate Eating Disorders: Systematic Review and Metasynthesis", journal="JMIR Ment Health", year="2025", month="Jan", day="3", volume="12", pages="e57795", keywords="eating disorders", keywords="anorexia", keywords="bulimia", keywords="binge eating", keywords="other specified feeding or eating disorder", keywords="OSFED", keywords="intervention", keywords="digital intervention", keywords="self-help", keywords="systematic review", abstract="Background: Digital interventions typically involve using smartphones or PCs to access online or downloadable self-help and may offer a more accessible and convenient option than face-to-face interventions for some people with mild to moderate eating disorders. They have been shown to substantially reduce eating disorder symptoms, but treatment dropout rates are higher than for face-to-face interventions. We need to understand user experiences and preferences for digital interventions to support the design and development of user-centered digital interventions that are engaging and meet users' needs. Objective: This study aims to understand user experiences and user preferences for digital interventions that aim to reduce mild to moderate eating disorder symptoms in adults. Methods: We conducted a metasynthesis of qualitative studies. We searched 6 databases for published and unpublished literature from 2013 to 2024. We searched for studies conducted in naturalistic or outpatient settings, using primarily unguided digital self-help interventions designed to reduce eating disorder symptoms in adults with mild to moderate eating disorders. We conducted a thematic synthesis using line-by-line coding of the results and findings from each study to generate themes. Results: A total of 8 studies were included after screening 3695 search results. Overall, 7 metathemes were identified. The identified metathemes included the appeal of digital interventions, role of digital interventions in treatment, value of support in treatment, communication at the right level, importance of engagement, shaping knowledge to improve eating disorder behaviors, and design of the digital intervention. Users had positive experiences with digital interventions and perceived them as helpful for self-reflection and mindfulness. Users found digital interventions to be convenient and flexible and that they fit with their lifestyle. Overall, users noticed reduced eating disorder thoughts and behaviors. However, digital interventions were not generally perceived as a sufficient treatment that could replace traditional face-to-face treatment. Users have individual needs, so an ideal intervention would offer personalized content and functions. Conclusions: Users found digital interventions for eating disorders practical and effective but stressed the need for interventions to address the full range of symptoms, severity, and individual needs. Future digital interventions should be cocreated with users and offer more personalization. Further research is needed to determine the appropriate balance of professional and peer support and whether these interventions should serve as the first step in the stepped care model. Trial Registration: PROSPERO CRD42023426932; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=426932 ", doi="10.2196/57795", url="https://mental.jmir.org/2025/1/e57795", url="http://www.ncbi.nlm.nih.gov/pubmed/39752210" } @Article{info:doi/10.2196/59145, author="Palacios, E. Jorge and Erickson-Ridout, K. Kathryn and Paik Kim, Jane and Buttlaire, Stuart and Ridout, Samuel and Argue, Stuart and Tregarthen, Jenna", title="Effects of a Digital Therapeutic Adjunct to Eating Disorder Treatment on Health Care Service Utilization and Clinical Outcomes: Retrospective Observational Study Using Electronic Health Records", journal="JMIR Ment Health", year="2024", month="Nov", day="27", volume="11", pages="e59145", keywords="digital therapeutics", keywords="app-augmented therapy", keywords="eating disorders", keywords="health care utilization", keywords="costs", keywords="real-world data", keywords="depression", keywords="emergency department", keywords="outpatient care", keywords="eating", keywords="treatment", keywords="therapy", keywords="retrospective analysis", keywords="electronic health record", keywords="patient", keywords="app", keywords="outpatient", abstract="Background: The need for scalable solutions facilitating access to eating disorder (ED) treatment services that are efficient, effective, and inclusive is a major public health priority. Remote access to synchronous and asynchronous support delivered via health apps has shown promise, but results are so far mixed, and there are limited data on whether apps can enhance health care utilization. Objective: This study aims to examine the effects of app-augmented treatment on clinical outcomes and health care utilization for patients receiving treatment for an ED in outpatient and intensive outpatient levels of care. Methods: Recovery Record was implemented in outpatient and intensive outpatient services in a California-based health maintenance organization. We examined outcomes for eligible patients with ED by comparing clinical and service utilization medical record data over a 6-month period after implementation with analogous data for the control group in the year prior. We used a logistic regression model and inverse-weighted estimates of the probability of treatment to adjust for treatment selection bias. Results: App-augmented treatment was associated with a significant decrease in emergency department visits (P<.001) and a significant increase in outpatient treatment utilization (P<.001). There was a significantly larger weight gain for patients in low-weight categories (ie, underweight, those with anorexia, or those with severe anorexia) with app-augmented treatment (treatment effect: 0.74, 0.25, and 0.35, respectively; P=.02), with a greater percentage of patients moving into a higher BMI class (P=.01). Conclusions: Integrating remote patient engagement apps into ED treatment plans can have beneficial effects on both clinical outcomes and service utilization. More research should be undertaken on long-term efficacy and cost-effectiveness to further explore the impact of digital health interventions in ED care. ", doi="10.2196/59145", url="https://mental.jmir.org/2024/1/e59145" } @Article{info:doi/10.2196/60865, author="Liu, Jianyi and Giannone, Alyssa and Wang, Hailing and Wetherall, Lucy and Juarascio, Adrienne", title="Understanding Patients' Preferences for a Digital Intervention to Prevent Posttreatment Deterioration for Bulimia-Spectrum Eating Disorders: User-Centered Design Study", journal="JMIR Form Res", year="2024", month="Nov", day="18", volume="8", pages="e60865", keywords="bulimia nervosa", keywords="binge eating", keywords="digital intervention", keywords="deterioration prevention", keywords="eating disorder", keywords="bulimia", keywords="digital health", keywords="deterioration", keywords="maintenance", keywords="mHealth", keywords="mobile health app", keywords="interviews", keywords="qualitative", keywords="user-centered design", keywords="psychotherapy", keywords="CBT", keywords="cognitive behavioral therapy", keywords="needs", keywords="preferences", keywords="mobile phone", abstract="Background: Deterioration rates after enhanced cognitive behavioral therapy (CBT-E) for patients with bulimia-spectrum eating disorders (BN-EDs) remain high, and decreased posttreatment skill use might be a particularly relevant contributor. Digital interventions could be an ideal option to improve skill use after treatment ends but they have yet to be investigated for BN-EDs. Objective: This study used a user-centered design approach to explore patients' interest in a digital intervention to prevent deterioration after CBT-E and their desired features. Methods: A total of 12 participants who previously received CBT-E for BN-EDs and experienced at least a partial response to treatment completed a qualitative interview asking about their interests and needs for an app designed to prevent deterioration after treatment ended. Participants were also presented with features commonly used in digital interventions for EDs and were asked to provide feedback. Results: All 12 participants expressed interest in using an app to prevent deterioration after treatment ended. In total, 11 participants thought the proposed feature of setting a goal focusing on skill use weekly would help improve self-accountability for skill use, and 6 participants supported the idea of setting goals related to specific triggers because they would know what skills to use in high-risk situations. A total of 10 participants supported the self-monitoring ED behaviors feature because it could increase their awareness levels. Participants also reported wanting to track mood (n=6) and food intake (n=5) besides the proposed tracking feature. A total of 10 participants reported wanting knowledge-based content in the app, including instructions on skill practice (n=6), general mental health strategies outside of EDs (n=4), guided mindfulness exercises (n=3), and nutrition recommendations (n=3). Eight participants reported a desire for the app to send targeted push notifications, including reminders of skill use (n=7) and inspirational quotes for encouragement (n=3). Finally, 8 participants reported wanting a human connection in the app, 6 participants wishing to interact with other users to support and learn from each other, and 4 participants wanting to connect with professionals as needed. Overall, participants thought that having an app targeting skill use could provide continued support and improve self-accountability, thus lowering the risk of decreased skill use after treatment ended. Conclusions: Insights from participants highlighted the perceived importance of continued support for continued skill use after treatment ended. This study also provided valuable design implications regarding potential features focusing on facilitating posttreatment skill use to include in digital deterioration prevention programs. Future research should examine the optimal approaches to deliver the core features identified in this study that could lead to higher continued skill use and a lower risk of deterioration in the long term. ", doi="10.2196/60865", url="https://formative.jmir.org/2024/1/e60865" } @Article{info:doi/10.2196/58363, author="Oliveira, Ashleigh and Wolff, John and Alfouzan, Nouf and Yu, Jin and Yahya, Asma and Lammy, Kayla and Nakamura, T. Manabu", title="A Novel Web App for Dietary Weight Management: Development, Implementation, and Usability Study", journal="JMIR Form Res", year="2024", month="Nov", day="11", volume="8", pages="e58363", keywords="health application", keywords="weight loss", keywords="behavior change technique", keywords="BCT", keywords="online weight loss program", keywords="weight monitoring", keywords="meal planning", keywords="sustainable weight loss", keywords="dietary fiber", keywords="mHealth", keywords="mobile health", abstract="Background: Online weight loss programs have ambiguous efficacy. There is a growing body of evidence that weight loss programs when combined with apps have better outcomes; however, many apps lack an evidence-based approach to dietary changes for weight loss and do not rely on a theoretical framework for behavior change. Objective: This study aimed to describe the development and the preliminary usability and acceptability testing of a web app that uses behavior change techniques (BCTs) to support users of a comprehensive online weight loss program. Methods: The weight loss program intervention components were nutrient and weight tracking charts that needed a remotely accessible and online format. The app was designed by nutrition researchers and developers in a collaborative effort. A review of BCTs in weight loss and web apps was performed as well as an assessment of user needs to inform the initial prototype. A preliminary app prototype, version 1.0, was provided to participants of a weight loss trial (N=30) to assess for feasibility of its use. A full app prototype, version 2.0, was feasibility and acceptability tested by trial participants (n=11) with formal feedback by Likert-scale survey and open-ended questions. In the final round of testing, a user group of scientists and developers (n=11) was selected to provide a structured 3-month review through which the group met weekly for collective feedback sessions. Results: The process resulted in a fully developed web app, MealPlot, by the Applied Research Institute, for meal planning and weight tracking that can be used by weight loss users and health professionals to track their patients. MealPlot includes a weight chart, a protein-fiber chart, and a chat feature. In addition, MealPlot has 2 distinct platforms, 1 for weight loss users and 1 for health professionals. Selected BCTs for incorporation into the app were goal setting, feedback, problem-solving, self-monitoring, and social support. Version 1.0 was used successfully to provide a functioning, online weight chart over the course of a 1-year trial. Version 2.0 provided a functional weight chart and meal planning page, but 8 out of 11 participants indicated MealPlot was difficult to use. Version 3.0 was developed based on feedback and strategies provided from user group testing. Conclusions: The web app, MealPlot, was developed to improve outcomes and functionality of an online weight loss program by providing a remote method of tracking weight, food intake, and connecting users to health professionals for consistent guidance that is not otherwise available in a traditional in-person health care setting. The final version 3.0 of the web app will be refined based on findings of a review study gathering feedback from health professionals and from actual weight loss users who are part of a clinical weight loss trial. ", doi="10.2196/58363", url="https://formative.jmir.org/2024/1/e58363" } @Article{info:doi/10.2196/60165, author="Gentile, Alessandra and Kristian, Yan Yosua and Cini, Erica", title="Effectiveness of Computer-Based Psychoeducational Self-Help Platforms for Eating Disorders (With or Without an Associated App): Protocol for a Systematic Review", journal="JMIR Res Protoc", year="2024", month="Nov", day="4", volume="13", pages="e60165", keywords="self-help", keywords="online self-help", keywords="eating disorders", keywords="anorexia nervosa", keywords="psychoeducational intervention", keywords="psychoeducation", keywords="binge eating", keywords="anorexia", keywords="bulimia", keywords="access to care", keywords="patient education", keywords="patient self-help", abstract="Background: Access to psychological health care is extremely difficult, especially for individuals with severely stigmatized disorders such as eating disorders (EDs). There has been an increase in children, adolescents, and adults with ED symptoms and ED, especially following the COVID-19 pandemic. Computer-based self-help platforms ({\textpm} associated apps) allow people to bridge the treatment gap and receive support when in-person treatment is unavailable or not preferred. Objective: The aim of this systematic review is to evaluate the effectiveness of computer-based self-help platforms for EDs, some of which may have associated apps. Methods: The proposed systematic review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. This review will report and evaluate the literature concerning the efficacy of self-help platforms for EDs. Articles were obtained from the Ovid MEDLINE, Embase, Global Health, and APA PsycInfo. The inclusion criteria included research with original data and gray literature; research evaluating the efficacy of web-based psychoeducational self-help platforms for EDs; people with an ED diagnosis, ED symptoms, at risk of developing EDs, or from the general population without ED-related behaviors; pre-- and post--computer-based {\textpm} associated apps intervention clinical outcome of ED symptoms; pre-- and post--computer-based {\textpm} associated apps intervention associated mental health difficulties; and literature in English. The exclusion criteria were solely guided self-help platforms, only in-person interventions with no computer-based {\textpm} associated apps comparison group, only in-person--delivered CBT, self-help platforms for conditions other than eating disorders, systematic reviews, meta-analyses, posters, leaflets, books, reviews, and research that only reported physical outcomes. Two independent authors used the search terms to conduct the initial search. The collated articles then were screened by their titles and abstracts, and finally, full-text screenings were conducted. The Cochrane Risk of Bias 2 tool will be used to assess the risks of bias in the included studies. Data extraction will be conducted, included studies will undergo narrative synthesis, and results will be presented in tables. The systematic review will be submitted to a peer-reviewed journal. Results: The authors conducted a database search for articles published by May 31, 2024. In total, 14 studies were included in the systematic review. Data charting, synthesis, and analysis were completed in Microsoft Excel by the end of July 2024. Results will be grouped based on the intervention stages. The results are expected to be published by the end of 2024. Overall, the systematic review found that computer-based self-help platforms are effective in reducing global ED psychopathology and ED-related behaviors. Conclusions: Self-help platforms are helpful first-stage resource in a tiered health care system. Trial Registration: PROSPERO CRD42024520866; https://tinyurl.com/5ys2unsw International Registered Report Identifier (IRRID): DERR1-10.2196/60165 ", doi="10.2196/60165", url="https://www.researchprotocols.org/2024/1/e60165", url="http://www.ncbi.nlm.nih.gov/pubmed/39495557" } @Article{info:doi/10.2196/57577, author="Thomas, Carien Pamela and Curtis, Kristina and Potts, W. Henry W. and Bark, Pippa and Perowne, Rachel and Rookes, Tasmin and Rowe, Sarah", title="Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis", journal="JMIR Ment Health", year="2024", month="Aug", day="1", volume="11", pages="e57577", keywords="digital health", keywords="eHealth", keywords="mobile health", keywords="mHealth", keywords="mobile apps", keywords="smartphone", keywords="behavior change", keywords="behavior change technique", keywords="systematic review", keywords="eating disorders", keywords="disordered eating", keywords="binge eating", keywords="bulimia nervosa", keywords="mobile phone", abstract="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: $\chi$21=9.7; P=.002; I{\texttwosuperior}=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 ", doi="10.2196/57577", url="https://mental.jmir.org/2024/1/e57577" } @Article{info:doi/10.2196/47382, author="Bould, Helen and Kennedy, Mari-Rose and Penton-Voak, Ian and Thomas, May Lisa and Bird, Jon and Biddle, Lucy", title="Exploring How Virtual Reality Could Be Used to Treat Eating Disorders: Qualitative Study of People With Eating Disorders and Clinicians Who Treat Them", journal="JMIR XR Spatial Comput", year="2024", month="May", day="14", volume="1", pages="e47382", keywords="eating disorders", keywords="virtual reality", keywords="anorexia nervosa", keywords="bulimia nervosa", keywords="EDNOS", keywords="treatment", keywords="immersive", keywords="clinicians", keywords="qualitative data", keywords="psychoeducation", keywords="therapeutic", keywords="limitations", abstract="Background: Immersive virtual reality (VR) interventions are being developed and trialed for use in the treatment of eating disorders. However, little work has explored the opinions of people with eating disorders, or the clinicians who treat them, on the possible use of VR in this context. Objective: This study aims to use qualitative methodology to explore the views of people with eating disorders, and clinicians who treat them, on the possible use of VR in the treatment of eating disorders. Methods: We conducted a series of focus groups and interviews with people with lived experience of eating disorders and clinicians on their views about VR and how it could potentially be used in the treatment of eating disorders. People with lived experience of eating disorders were recruited between October and December 2020, with focus groups held online between November 2020 and February 2021; clinicians were recruited in September 2021 and interviewed between September and October 2021. We took a thematic approach to analyzing the resulting qualitative data. Results: We conducted 3 focus groups with 10 individuals with a current or previous eating disorder, 2 focus groups with 4 participants, and 1 with 2 participants. We held individual interviews with 4 clinicians experienced in treating people with eating disorders. Clinicians were all interviewed one-to-one because of difficulties in scheduling mutually convenient groups. We describe themes around representing the body in VR, potential therapeutic uses for VR, the strengths and limitations of VR in this context, and the practicalities of delivering VR therapy. Suggested therapeutic uses were to practice challenging situations around food-related and weight/appearance-related scenarios and interactions, to retrain attention, the representation of the body, to represent the eating disorder, for psychoeducation, and to enable therapeutic conversations with oneself. There was a substantial agreement between the groups on these themes. Conclusions: People with lived experience of eating disorders and clinicians with experience in treating eating disorders generated many ideas as to how VR could be used as a part of eating disorders treatment. They were also aware of potential limitations and expressed the need for caution around how bodies are represented in a VR setting. ", doi="10.2196/47382", url="https://xr.jmir.org/2024/1/e47382" } @Article{info:doi/10.2196/46036, author="Chew, Jocelyn Han Shi and Chew, WS Nicholas and Loong, Ern Shaun Seh and Lim, Lin Su and Tam, Wilson Wai San and Chin, Han Yip and Chao, M. Ariana and Dimitriadis, K. Georgios and Gao, Yujia and So, Yan Jimmy Bok and Shabbir, Asim and Ngiam, Yuan Kee", title="Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation", journal="J Med Internet Res", year="2024", month="May", day="7", volume="26", pages="e46036", keywords="artificial intelligence", keywords="chatbot", keywords="chatbots", keywords="weight", keywords="overweight", keywords="eating", keywords="food", keywords="weight loss", keywords="mHealth", keywords="mobile health", keywords="app", keywords="apps", keywords="applications", keywords="self-regulation", keywords="self-monitoring", keywords="anxiety", keywords="depression", keywords="consideration of future consequences", keywords="mental health", keywords="conversational agent", keywords="conversational agents", keywords="eating behavior", keywords="healthy eating", keywords="food consumption", keywords="obese", keywords="obesity", keywords="diet", keywords="dietary", abstract="Background: A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one's self-regulation over momentary eating impulses. Objective: This study aims to examine the feasibility and effectiveness of a novel artificial intelligence--assisted weight management app in improving eating behaviors in a Southeast Asian cohort. Methods: A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation. Results: The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean --0.32, SD 1.16; P<.001), snacking habits (mean --0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean --0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1\%) of the 862 meals skipped. Of the 230 participants, 80 (34.8\%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4\% (21/251). Conclusions: eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity. Trial Registration: ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803 ", doi="10.2196/46036", url="https://www.jmir.org/2024/1/e46036", url="http://www.ncbi.nlm.nih.gov/pubmed/38713909" } @Article{info:doi/10.2196/51581, author="Lim, Heemoon and Lee, Hyejung", title="Eating Habits and Lifestyle Factors Related to Childhood Obesity Among Children Aged 5-6 Years: Cluster Analysis of Panel Survey Data in Korea", journal="JMIR Public Health Surveill", year="2024", month="Apr", day="5", volume="10", pages="e51581", keywords="BMI", keywords="body mass index", keywords="childhood obesity", keywords="cluster analysis", keywords="healthy eating", keywords="healthy lifestyle", keywords="pediatric obesity", keywords="preschool child", keywords="prevention", keywords="unsupervised machine learning", abstract="Background: Childhood obesity has emerged as a major health issue due to the rapid growth in the prevalence of obesity among young children worldwide. Establishing healthy eating habits and lifestyles in early childhood may help children gain appropriate weight and further improve their health outcomes later in life. Objective: This study aims to classify clusters of young children according to their eating habits and identify the features of each cluster as they relate to childhood obesity. Methods: A total of 1280 children were selected from the Panel Study on Korean Children. Data on their eating habits (eating speed, mealtime regularity, consistency of food amount, and balanced eating), sleep hours per day, outdoor activity hours per day, and BMI were obtained. We performed a cluster analysis on the children's eating habits using k-means methods. We conducted ANOVA and chi-square analyses to identify differences in the children's BMI, sleep hours, physical activity, and the characteristics of their parents and family by cluster. Results: At both ages (ages 5 and 6 years), we identified 4 clusters based on the children's eating habits. Cluster 1 was characterized by a fast eating speed (fast eaters); cluster 2 by a slow eating speed (slow eaters); cluster 3 by irregular eating habits (poor eaters); and cluster 4 by a balanced diet, regular mealtimes, and consistent food amounts (healthy eaters). Slow eaters tended to have the lowest BMI (P<.001), and a low proportion had overweight and obesity at the age of 5 years (P=.03) and 1 year later (P=.005). There was a significant difference in sleep time (P=.01) and mother's education level (P=.03) at the age of 5 years. Moreover, there was a significant difference in sleep time (P=.03) and the father's education level (P=.02) at the age of 6 years. Conclusions: Efforts to establish healthy eating habits in early childhood may contribute to the prevention of obesity in children. Specifically, providing dietary guidance on a child's eating speed can help prevent childhood obesity. This research suggests that lifestyle modification could be a viable target to decrease the risk of childhood obesity and promote the development of healthy children. Additionally, we propose that future studies examine long-term changes in obesity resulting from lifestyle modifications in children from families with low educational levels. ", doi="10.2196/51581", url="https://publichealth.jmir.org/2024/1/e51581", url="http://www.ncbi.nlm.nih.gov/pubmed/38578687" } @Article{info:doi/10.2196/51558, author="Anastasiadou, Dimitra and Herrero, Pol and Garcia-Royo, Paula and V{\'a}zquez-De Sebasti{\'a}n, Julia and Slater, Mel and Spanlang, Bernhard and {\'A}lvarez de la Campa, Elena and Ciudin, Andreea and Comas, Marta and Ramos-Quiroga, Antoni Josep and Lusilla-Palacios, Pilar", title="Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial", journal="J Med Internet Res", year="2024", month="Apr", day="5", volume="26", pages="e51558", keywords="obesity", keywords="virtual reality", keywords="psychological treatment", keywords="embodiment", keywords="motivational interviewing", keywords="self-conversation", abstract="Background: Virtual reality (VR) interventions, based on cognitive behavioral therapy principles, have been proven effective as complementary tools in managing obesity and have been associated with promoting healthy behaviors and addressing body image concerns. However, they have not fully addressed certain underlying causes of obesity, such as a lack of motivation to change, low self-efficacy, and the impact of weight stigma interiorization, which often impede treatment adherence and long-term lifestyle habit changes. To tackle these concerns, this study introduces the VR self-counseling paradigm, which incorporates embodiment and body-swapping techniques, along with motivational strategies, to help people living with obesity effectively address some of the root causes of their condition. Objective: This study aims to assess the clinical efficacy of ConVRself (Virtual Reality self-talk), a VR platform that allows participants to engage in motivational self-conversations. Methods: A randomized controlled trial was conducted with 68 participants from the bariatric surgery waiting list from the obesity unit of the Vall d'Hebron University Hospital in Barcelona, Spain. Participants were assigned to 1 of 3 groups: a control group (CG), which only received treatment as usual from the obesity unit; experimental group 1 (EG1), which, after intensive motivational interviewing training, engaged in 4 sessions of VR-based self-conversations with ConVRself, and underwent embodiment and body-swapping techniques; and experimental group 2 (EG2), which engaged in 4 VR-based sessions led by a virtual counselor with a prerecorded discourse, and only underwent the embodiment technique. In the case of both EG1 and EG2, the VR interventions were assisted by a clinical researcher. Readiness to change habits, eating habits, and psychological variables, as well as adherence and satisfaction with ConVRself were measured at baseline, after the intervention, 1 week after the intervention, and 4 weeks after the intervention. Results: Regarding the primary outcomes, EG1 (24/68, 35\%) and EG2 (22/68, 32\%) showed significant improvements in confidence to lose weight compared to the CG (22/68, 32\%) at all assessment points ($\beta$=?.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG ($\beta$=?.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating ($\beta$=.71; P=.01) and emotional eating ($\beta$=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants ($\beta$=.65; P=.01). In addition, participants from the experimental groups reported high adherence and satisfaction with the VR platform (EG1: mean 59.82, SD 4.00; EG2: mean 58.43, SD 5.22; d=0.30, 95\% CI ?0.30 to 0.89). Conclusions: This study revealed that using VR self-conversations, based on motivational interviewing principles, may have benefits in helping people with obesity to enhance their readiness to change habits and self-efficacy, as well as reduce dysfunctional eating behaviors and anxiety. Trial Registration: ClinicalTrials.gov NCT05094557; https://www.clinicaltrials.gov/study/NCT05094557 ", doi="10.2196/51558", url="https://www.jmir.org/2024/1/e51558", url="http://www.ncbi.nlm.nih.gov/pubmed/38578667" } @Article{info:doi/10.2196/55193, author="Edwards, Katie and Croker, Helen and Farrow, Claire and Haycraft, Emma and Herle, Moritz and Llewellyn, Clare and Pickard, Abigail and Blissett, Jacqueline", title="Examining Parent Mood, Feeding Context, and Feeding Goals as Predictors of Feeding Practices Used by Parents of Preschool Children With Avid Eating Behavior: Protocol for an Ecological Momentary Assessment Study", journal="JMIR Res Protoc", year="2024", month="Mar", day="19", volume="13", pages="e55193", keywords="ecological momentary assessment", keywords="avid eating", keywords="children's eating behavior", keywords="parental feeding practices", keywords="feeding behaviour", keywords="parent", keywords="children", keywords="eating behaviour", keywords="obesity", keywords="environmental factors", keywords="observational study", keywords="feeding", keywords="United Kingdom", abstract="Background: An avid eating behavior profile is characterized by a greater interest in food and a tendency to overeat in response to negative emotions. Parents use specific strategies to manage feeding interactions with children with avid eating behavior. While momentary and contextual factors, such as parental mood, have been found to influence parental feeding practices, there is a lack of research examining parents' daily experiences of feeding children with avid eating behavior. Examining this is important because parental feeding practices are key levers in tailored interventions to support children's healthy eating behavior. Objective: We aim to describe the ecological momentary assessment methods and procedures used in the APPETItE (Appetite in Preschoolers: Producing Evidence for Tailoring Interventions Effectively) project, which aims to examine how variation in parental mood, feeding goals, and the context of eating occasions affect the parental feeding practices used to manage feeding interactions with children with an avid eating behavior profile. Methods: Participants are primary caregivers from the APPETItE cohort who have a preschool-age child (aged 3-5 years) with an avid eating behavior profile. Caregivers complete a 10-day ecological momentary assessment period using signal- and event-contingent surveys to examine (1) mood and stress, (2) parental feeding goals, and (3) contextual factors as predictors of parental feeding practices. Results: Recruitment and data collection began in October 2023 and is expected to be completed by spring 2024. The data have a 3-level structure: repeated measurements (level 1) nested within days (level 2) nested within an individual (level 3). Thus, lag-dependent models will be conducted to test the main hypotheses. Conclusions: The findings from this study will provide an understanding of caregivers' daily experiences of feeding preschool children with avid eating behavior, who are at greater risk for the development of obesity. Understanding the predictors of feeding practices at the moment they occur, and across various contexts, will inform the development of tailored resources to support caregivers in managing children's avid eating behavior. International Registered Report Identifier (IRRID): DERR1-10.2196/55193 ", doi="10.2196/55193", url="https://www.researchprotocols.org/2024/1/e55193", url="http://www.ncbi.nlm.nih.gov/pubmed/38502178" } @Article{info:doi/10.2196/48817, author="O'Hara, Cathal and Gibney, R. Eileen", title="Dietary Intake Assessment Using a Novel, Generic Meal--Based Recall and a 24-Hour Recall: Comparison Study", journal="J Med Internet Res", year="2024", month="Feb", day="14", volume="26", pages="e48817", keywords="meal patterns", keywords="eating behaviors", keywords="eating occasions", keywords="nutrition assessment", keywords="dietary intake assessment", keywords="24-hour recall", keywords="relative validity", abstract="Background: Dietary intake assessment is an integral part of addressing suboptimal dietary intakes. Existing food-based methods are time-consuming and burdensome for users to report the individual foods consumed at each meal. However, ease of use is the most important feature for individuals choosing a nutrition or diet app. Intakes of whole meals can be reported in a manner that is less burdensome than reporting individual foods. No study has developed a method of dietary intake assessment where individuals report their dietary intakes as whole meals rather than individual foods. Objective: This study aims to develop a novel, meal-based method of dietary intake assessment and test its ability to estimate nutrient intakes compared with that of a web-based, 24-hour recall (24HR). Methods: Participants completed a web-based, generic meal--based recall. This involved, for each meal type (breakfast, light meal, main meal, snack, and beverage), choosing from a selection of meal images those that most represented their intakes during the previous day. Meal images were based on generic meals from a previous study that were representative of the actual meal intakes in Ireland. Participants also completed a web-based 24HR. Both methods were completed on the same day, 3 hours apart. In a crossover design, participants were randomized in terms of which method they completed first. Then, 2 weeks after the first dietary assessments, participants repeated the process in the reverse order. Estimates of mean daily nutrient intakes and the categorization of individuals according to nutrient-based guidelines (eg, low, adequate, and high) were compared between the 2 methods. P values of less than .05 were considered statistically significant. Results: In total, 161 participants completed the study. For the 23 nutrient variables compared, the median percentage difference between the 2 methods was 7.6\% (IQR 2.6\%-13.2\%), with P values ranging from <.001 to .97, and out of 23 variables, effect sizes for the differences were small for 19 (83\%) variables, moderate for 2 (9\%) variables, and large for 2 (9\%) variables. Correlation coefficients were statistically significant (P<.05) for 18 (78\%) of the 23 variables. Statistically significant correlations ranged from 0.16 to 0.45, with median correlation of 0.32 (IQR 0.25-0.40). When participants were classified according to nutrient-based guidelines, the proportion of individuals who were classified into the same category ranged from 52.8\% (85/161) to 84.5\% (136/161). Conclusions: A generic meal--based method of dietary intake assessment provides estimates of nutrient intake comparable with those provided by a web-based 24HR but with varying levels of agreement among nutrients. Further studies are required to refine and improve the generic recall across a range of nutrients. Future studies will consider user experience including the potential feasibility of incorporating image recognition of whole meals into the generic recall. ", doi="10.2196/48817", url="https://www.jmir.org/2024/1/e48817", url="http://www.ncbi.nlm.nih.gov/pubmed/38354039" } @Article{info:doi/10.2196/54253, author="Huffman, Goodgame Landry and Lawrence-Sidebottom, Darian and Beam, Brenna Aislinn and Parikh, Amit and Guerra, Rachael and Roots, Monika and Huberty, Jennifer", title="Improvements in Adolescents' Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study", journal="JMIR Form Res", year="2024", month="Jan", day="31", volume="8", pages="e54253", keywords="behavioral care", keywords="mental health", keywords="web-based coaching", keywords="web-based therapy", keywords="eating disorders", keywords="eating", keywords="anorexia", keywords="coach", keywords="coaching", keywords="pediatric", keywords="pediatrics", keywords="adolescent", keywords="adolescents", keywords="teen", keywords="teens", keywords="teenager", keywords="teenagers", keywords="digital mental health intervention", keywords="DMHI", keywords="collaborative", keywords="digital health", abstract="Background: Young people today are exhibiting increasing rates of disordered eating behaviors, as well as eating disorders (EDs), alongside other mental and behavioral problems such as anxiety and depression. However, limited access to mental health care means that EDs, disordered eating behaviors, and comorbid mental health problems are often underdiagnosed and undertreated. Digital mental health interventions (DMHIs) offer accessible and scalable alternatives to traditional treatment modalities, but their effectiveness has not been well established among adolescents with EDs and disordered eating behaviors. Objective: This study uses data from a collaborative care pediatric DMHI to determine whether participation in a DMHI is associated with a reduction in adolescents' disordered eating behaviors. Methods: Adolescent members in care with Bend Health Inc completed the SCOFF questionnaire at baseline (before the start of care) and approximately every month during care to assess disordered eating behaviors. They also completed assessments of mental health symptoms at baseline. Member characteristics, mental health symptoms, and disordered eating behaviors of adolescents with elevated SCOFF scores at baseline (before the start of care) were compared to those of adolescents with nonelevated SCOFF scores at baseline. Members participated in web-based coaching or therapy sessions throughout the duration of mental health care. Results: Compared to adolescents with nonelevated SCOFF scores (n=520), adolescents with elevated SCOFF scores (n=169) were predominantly female and exhibited higher rates of elevated anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4\% (n=70) of adolescents with elevated SCOFF scores, and each additional month of participation was associated with greater improvements in disordered eating behaviors (F1,233=72.82; P<.001). Conclusions: Our findings offer promising preliminary evidence that participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms. ", doi="10.2196/54253", url="https://formative.jmir.org/2024/1/e54253", url="http://www.ncbi.nlm.nih.gov/pubmed/38294855" } @Article{info:doi/10.2196/52193, author="Myers, A. Candice and Beyl, A. Robbie and Hsia, S. Daniel and Harris, N. Melissa and Reed, J. Isabella and Eliser, D. Danielle and Bagneris, Lauren and Apolzan, W. John", title="Effects of Episodic Food Insecurity on Psychological and Physiological Responses in African American Women With Obesity (RESPONSES): Protocol for a Longitudinal Observational Cohort Study", journal="JMIR Res Protoc", year="2023", month="Dec", day="20", volume="12", pages="e52193", keywords="food security", keywords="body weight", keywords="racially minoritized group", keywords="low income", keywords="stress", keywords="cortisol", keywords="allostatic load", abstract="Background: Food insecurity is a risk factor for multiple chronic diseases, including obesity. Importantly, both food insecurity and obesity are more prevalent in African American women than in other groups. Furthermore, food insecurity is considered a cyclic phenomenon, with episodes of food adequacy (ie, enough food to eat) and food shortage (ie, not enough food to eat). More research is needed to better understand why food insecurity is linked to obesity, including acknowledging the episodic nature of food insecurity as a stressor and identifying underlying mechanisms. Objective: The objective of this study is to investigate the episodic nature of food insecurity as a stressor via responses in body weight and psychological and physiological parameters longitudinally and do so in a health-disparate population---African American women. Methods: We enrolled 60 African American women (food-insecure cohort: n=30, 50\%; food-secure cohort: n=30, 50\%) aged 18-65 years with obesity (BMI 30-50 kg/m2) to measure (1) daily body weight remotely over 22 weeks and (2) psychological and physiological parameters via clinic assessments at the beginning and end of the 22-week study. Furthermore, we are assessing episodes of food insecurity, stress, hedonic eating, and appetite on a weekly basis. We hypothesize that food-insecure African American women with obesity will demonstrate increased body weight and changes in psychological and physiological end points, whereas food-secure African American women with obesity will not. We are also examining associations between changes in psychological and physiological parameters and changes in body weight and performing a mediation analysis on the psychological parameters assessed at the study midpoint. Psychological questionnaires are used to assess stress; executive function, decision-making, and motivation; and affect and nonhomeostatic eating. Physiological measurements are used to evaluate the levels of cortisol, dehydroepiandrosterone-sulfate (DHEA-S), C-reactive protein, thyroid hormones, blood glucose, glycated hemoglobin, and insulin, as well as allostatic load. Results: This study has completed participant recruitment (n=60). At the time of study enrollment, the mean age of the participants was almost 47 (SD 10.8) years, and they had a mean BMI of 39.6 (SD 5.31) kg/m2. All data are anticipated to be collected by the end of 2023. Conclusions: We believe that this is the first study to examine changes in body weight and psychological and physiological factors in food-insecure African American women with obesity. This study has significant public health implications because it addresses the cyclic nature of food insecurity to identify underlying mechanisms that can be targeted to mitigate the adverse relationship between food insecurity and obesity and reduce health disparities in minority populations. Trial Registration: ClinicalTrials.gov NCT05076487; https://clinicaltrials.gov/study/NCT05076487 International Registered Report Identifier (IRRID): DERR1-10.2196/52193 ", doi="10.2196/52193", url="https://www.researchprotocols.org/2023/1/e52193", url="http://www.ncbi.nlm.nih.gov/pubmed/38117554" } @Article{info:doi/10.2196/50714, author="Bond, S. Dale and Papasavas, K. Pavlos and Raynor, A. Hollie and Grilo, M. Carlos and Steele, R. Vaughn", title="Transcranial Magnetic Stimulation for Reducing the Relative Reinforcing Value of Food in Adult Patients With Obesity Pursuing Metabolic and Bariatric Surgery: Protocol for a Pilot, Within-Participants, Sham-Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Nov", day="6", volume="12", pages="e50714", keywords="obesity", keywords="repetitive transcranial magnetic stimulation", keywords="food reinforcement", keywords="hedonic hunger", keywords="electroencephalography", keywords="metabolic and bariatric surgery", abstract="Background: Metabolic and bariatric surgery (MBS) is the most effective and durable obesity treatment. However, there is heterogeneity in weight outcomes, which is partially attributed to variability in appetite and eating regulation. Patients with a strong desire to eat in response to the reward of palatable foods are more likely to overeat and experience suboptimal outcomes. This subgroup, classified as at risk, may benefit from repetitive transcranial magnetic stimulation (rTMS), a noninvasive brain stimulation technique that shows promise for reducing cravings and consumption of addictive drugs and food; no study has evaluated how rTMS affects the reinforcing value of food and brain reward processing in the context of MBS. Objective: The goal of the Transcranial Magnetic Stimulation to Reduce the Relative Reinforcing Value of Food (RESTRAIN) study is to perform an initial rTMS test on the relative reinforcing value (RRV) of food (the reinforcing value of palatable food compared with money) among adult patients who are pursuing MBS and report high food reinforcement. Using a within-participants sham-controlled crossover design, we will compare the active and sham rTMS conditions on pre- to posttest changes in the RRV of food (primary objective) and the neural modulation of reward, measured via electroencephalography (EEG; secondary objective). We hypothesize that participants will show larger decreases in food reinforcement and increases in brain reward processing after active versus sham rTMS. Methods: Participants (n=10) will attend 2 study sessions separated by a washout period. They will be randomized to active rTMS on 1 day and sham rTMS on the other day using a counterbalanced schedule. For both sessions, participants will arrive fasted in the morning and consume a standardized breakfast before being assessed on the RRV of food and reward tasks via EEG before and after rTMS of the left dorsolateral prefrontal cortex. Results: Recruitment and data collection began in December 2022. As of October 2023, overall, 52 patients have been screened; 36 (69\%) screened eligible, and 17 (47\%) were enrolled. Of these 17 patients, 3 (18\%) were excluded before rTMS, 5 (29\%) withdrew, 4 (24\%) are in the process of completing the protocol, and 5 (29\%) completed the protocol. Conclusions: The RESTRAIN study is the first to test whether rTMS can target neural reward circuits to reduce behavioral (RRV) and neural (EEG) measures of food reward in patients who are pursuing MBS. If successful, the results would provide a rationale for a fully powered trial to examine whether rTMS-related changes in food reinforcement translate into healthier eating patterns and improved MBS outcomes. If the results do not support our hypotheses, we will continue this line of research to evaluate whether additional rTMS sessions and pulses as well as different stimulation locations produce clinically meaningful changes in food reinforcement. Trial Registration: ClinicalTrials.gov NCT05522803; https://clinicaltrials.gov/study/NCT05522803 International Registered Report Identifier (IRRID): DERR1-10.2196/50714 ", doi="10.2196/50714", url="https://www.researchprotocols.org/2023/1/e50714", url="http://www.ncbi.nlm.nih.gov/pubmed/37930756" } @Article{info:doi/10.2196/46310, author="Sun, Shufang and Nardi, William and Murphy, Matthew and Scott, Ty and Saadeh, Frances and Roy, Alexandra and Brewer, Judson", title="Mindfulness-Based Mobile Health to Address Unhealthy Eating Among Middle-Aged Sexual Minority Women With Early Life Adversity: Mixed Methods Feasibility Trial", journal="J Med Internet Res", year="2023", month="Sep", day="26", volume="25", pages="e46310", keywords="mobile health", keywords="mindfulness", keywords="obesity", keywords="sexual minority women", keywords="early life adversity", keywords="cell phone", keywords="mobile phone", abstract="Background: Sexual minority women (lesbian, gay, bisexual, pansexual, queer, and other nonheterosexual women) remain considerably underrepresented in health research despite being at a higher risk for diabetes and obesity as well as stigma and psychological distress than their heterosexual peers. In addition, early life adversity (ELA) is prevalent among sexual minority women, which further increases risks for obesity, psychological distress, and poor cardiovascular health. App-based mindfulness interventions are potentially promising for this group in mitigating the adverse health effects of ELA, reducing food craving and unhealthy eating, addressing the risks associated with obesity. Objective: This mixed methods feasibility trial aimed to test a mindfulness-based mobile health approach for middle-aged sexual minority women (aged 30-55 years) with ELA and overweight or obesity (BMI ?25 kg/m2) to improve health outcomes. Methods: The single-arm trial was advertised on social media and various lesbian, gay, bisexual, transgender, and queer web-based groups. At baseline, after the intervention (2 months), and at the 4-month follow-up, participants completed assessments of primary outcomes (food craving, emotional eating, and weight via a mailed scale) and secondary outcomes (depression, anxiety, mindfulness, and emotion dysregulation). A standardized weight measure was mailed to participants for weight reporting. Feasibility and acceptability were assessed after the intervention via surveys and semistructured exit interviews. Results: We screened 442 individuals, among which 30 eligible sexual minority women (mean age 40.20, SD 7.15 years) from various US regions were enrolled in the study. At baseline, 86\% (26/30) and 80\% (24/30) of participants had elevated depressive and anxiety symptoms, respectively. Among the 30 enrolled participants, 20 (66\%) completed all intervention modules, 25 (83\%) were retained at the 2-month follow-up, and 20 (66\%) were retained at the 4-month follow-up. None reported adverse effects. From baseline to the 4-month follow-up, large effects were found in food craving (Cohen d=1.64) and reward-based eating (Cohen d=1.56), whereas small effects were found with weight (Cohen d=0.20; 4.21 kg on average). Significant improvements were also found in the secondary outcomes (depression, Cohen d=0.98; anxiety, Cohen d=0.50; mindfulness, Cohen d=0.49; and emotion dysregulation, Cohen d=0.44; all P<.05). Participants with higher levels of parental verbal and emotional abuse were particularly responsive to the intervention. Participants reported that the program aligned with their goals and expectations, was easy to use, and facilitated changes in eating behavior and mental health. Barriers to engagement included the need for diverse teachers, individualized support, and body positive language. Conclusions: This early phase feasibility trial provides proof-of-concept support for a mindfulness mobile health approach to improve obesity-related outcomes among sexual minority women and warrants a larger randomized controlled trial in the future. The findings also suggest the need to address trauma and psychological health when addressing weight-related outcomes among sexual minority women. ", doi="10.2196/46310", url="https://www.jmir.org/2023/1/e46310", url="http://www.ncbi.nlm.nih.gov/pubmed/37751273" } @Article{info:doi/10.2196/49828, author="Hamatani, Sayo and Matsumoto, Kazuki and Andersson, Gerhard and Tomioka, Yukiko and Numata, Shusuke and Kamashita, Rio and Sekiguchi, Atsushi and Sato, Yasuhiro and Fukudo, Shin and Sasaki, Natsuki and Nakamura, Masayuki and Otani, Ryoko and Sakuta, Ryoichi and Hirano, Yoshiyuki and Kosaka, Hirotaka and Mizuno, Yoshifumi", title="Guided Internet-Based Cognitive Behavioral Therapy for Women With Bulimia Nervosa: Protocol for a Multicenter Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Sep", day="19", volume="12", pages="e49828", keywords="bulimia nervosa", keywords="internet-based cognitive behavioral therapy", keywords="ICBT", keywords="randomized controlled trial", keywords="RCT", keywords="protocol", keywords="randomized", keywords="controlled trial", keywords="bulimia", keywords="eating", keywords="cognitive behavioral therapy", keywords="CBT", keywords="binge eating", keywords="purging", keywords="mobile phone", abstract="Background: Individual face-to-face cognitive behavioral therapy is known to be effective for bulimia nervosa (BN). Since foods vary considerably between regions and cultures in which patients live, cultural adaptation of the treatment program is particularly important in cognitive behavioral therapy for BN. Recently, an internet-based cognitive behavioral therapy (ICBT) program was developed for Japanese women with BN, adapted to the Japanese food culture. However, no previous randomized controlled trial has examined the effectiveness of ICBT. Objective: This paper presents a research protocol for strategies to examine the effects of guided ICBT. Methods: This study is designed as a multicenter, prospective, assessor-blinded randomized controlled trial. The treatment groups will be divided into treatment as usual (TAU) alone as the control group and ICBT combined with TAU as the intervention group. The primary outcome is the total of binge eating and purging behaviors assessed before and after treatment by an independent assessor. Secondary outcomes will include measures of eating disorder severity, depression, anxiety, quality of life, treatment satisfaction, and working alliances. Treatment satisfaction and working alliances will be measured post assessment only. Other measures will be assessed at baseline, post intervention, and follow-up, and the outcomes will be analyzed on an intention-to-treat basis. Results: This study will be conducted at 7 different medical institutions in Japan from August 2022 to October 2026. Recruitment of participants began on August 19, 2022, and recruitment is scheduled to continue until July 2024. The first participants were registered on September 8, 2022. Conclusions: This is the first multicenter randomized controlled trial in Japan comparing the effectiveness of ICBT and TAU in patients with BN. Trial Registration: University Hospital Medical Information Network UMIN000048732; https://center6.umin.ac.jp/cgi-open-bin/ctr\_e/ctr\_view.cgi?recptno=R000055522 International Registered Report Identifier (IRRID): DERR1-10.2196/49828 ", doi="10.2196/49828", url="https://www.researchprotocols.org/2023/1/e49828", url="http://www.ncbi.nlm.nih.gov/pubmed/37725414" } @Article{info:doi/10.2196/45407, author="Woo, Sarah and Jung, Sunho and Lim, Hyunjung and Kim, YoonMyung and Park, Hee Kyung", title="Exploring the Effect of the Dynamics of Behavioral Phenotypes on Health Outcomes in an mHealth Intervention for Childhood Obesity: Longitudinal Observational Study", journal="J Med Internet Res", year="2023", month="Aug", day="17", volume="25", pages="e45407", keywords="behavioral dynamics", keywords="behavioral phenotype", keywords="functional data analysis", keywords="FDA", keywords="machine learning analysis", keywords="mobile health", keywords="mHealth", keywords="obesity intervention", keywords="pediatric obesity", keywords="mobile phone", abstract="Background: Advancements in mobile health technologies and machine learning approaches have expanded the framework of behavioral phenotypes in obesity treatment to explore the dynamics of temporal changes. Objective: This study aimed to investigate the dynamics of behavioral changes during obesity intervention and identify behavioral phenotypes associated with weight change using a hybrid machine learning approach. Methods: In total, 88 children and adolescents (ages 8-16 years; 62/88, 71\% male) with age- and sex-specific BMI ?85th percentile participated in the study. Behavioral phenotypes were identified using a hybrid 2-stage procedure based on the temporal dynamics of adherence to the 5 behavioral goals during the intervention. Functional principal component analysis was used to determine behavioral phenotypes by extracting principal component factors from the functional data of each participant. Elastic net regression was used to investigate the association between behavioral phenotypes and weight change. Results: Functional principal component analysis identified 2 distinctive behavioral phenotypes, which were named the high or low adherence level and late or early behavior change. The first phenotype explained 47\% to 69\% of each factor, whereas the second phenotype explained 11\% to 17\% of the total behavioral dynamics. High or low adherence level was associated with weight change for adherence to screen time ($\beta$=?.0766, 95\% CI ?.1245 to ?.0312), fruit and vegetable intake ($\beta$=.1770, 95\% CI .0642-.2561), exercise ($\beta$=?.0711, 95\% CI ?.0892 to ?.0363), drinking water ($\beta$=?.0203, 95\% CI ?.0218 to ?.0123), and sleep duration. Late or early behavioral changes were significantly associated with weight loss for changes in screen time ($\beta$=.0440, 95\% CI .0186-.0550), fruit and vegetable intake ($\beta$=?.1177, 95\% CI ?.1441 to ?.0680), and sleep duration ($\beta$=?.0991, 95\% CI ?.1254 to ?.0597). Conclusions: Overall level of adherence, or the high or low adherence level, and a gradual improvement or deterioration in health-related behaviors, or the late or early behavior change, were differently associated with weight loss for distinctive obesity-related lifestyle behaviors. A large proportion of health-related behaviors remained stable throughout the intervention, which indicates that health care professionals should closely monitor changes made during the early stages of the intervention. Trial Registration: Clinical Research Information Science KCT0004137; https://tinyurl.com/ytxr83ay ", doi="10.2196/45407", url="https://www.jmir.org/2023/1/e45407", url="http://www.ncbi.nlm.nih.gov/pubmed/37590040" } @Article{info:doi/10.2196/45098, author="Mey, T. Jacob and Karpinski, A. Christine and Yang, Shengping and Madere, D. Joseph and Piattoly, Tavis and Harper, Ronnie and Kirwan, P. John", title="Factors Influencing Nutritional Intake and Interests in Educational Content of Athletes and Sport Professionals Toward the Development of a Clinician-Supported Mobile App to Combat Relative Energy Deficiency in Sport: Formative Research and a Description of App Functions", journal="JMIR Form Res", year="2023", month="Jul", day="26", volume="7", pages="e45098", keywords="dietitian", keywords="malnutrition", keywords="mHealth", keywords="mobile health", keywords="performance", keywords="RED-S", keywords="relative energy deficiency in sport", keywords="sports nutrition", keywords="technology", abstract="Background: Relative energy deficiency in sport (RED-S) as a consequence of athlete malnutrition remains a prominent issue. However, it remains underrecognized, in part due to the perceived outward health of athletes. The Eat2Win app was designed to combat RED-S and athlete malnutrition by providing education, behavior modification, and direct communication with expert sports dietitians to athletes and sport professionals (professionals who work with athletes, eg, sport coaches and athletic trainers). Objective: The purpose of this formative research was to gain critical insight on motivators and barriers to optimal nutritional intake from both the athletes' and sport professionals' perspectives. Additionally, since these 2 groups represent the primary end users of an app aimed at improving athlete nutrition and reducing the risk of RED-S, a secondary objective was to gain insight on the preferences and perceptions of app-based educational content and functionality. Methods: An electronic survey was developed by an interdisciplinary team of experts. Survey questions were established based upon prevailing literature, professional dietetic field experience, and app design considerations to obtain respondent knowledge on key sports nutrition topics along with motivations and barriers to meal choices. Additionally, the survey included questions about the development of an integrative, clinician-support app aimed at addressing RED-S. These questions included preferences for educational content, modes of in-app information, and communication delivery for the target population (app end users: athletes and sport professionals). The survey was distributed through Research Electronic Data Capture (REDCap) to athletes and sport professionals using targeted email, social media, and community engagement campaigns. The electronic survey was available from May 4 to August 2, 2022. Results: Survey respondents (n=1352) included athletes and professionals who work with athletes from a variety of settings, like high school, collegiate, professional, and club sports. Respondents reported high interest in 8 core sports nutrition topics. The preferred modes of information and communication delivery were visual formats (eg, videos and infographics) and in-app alerts (eg, direct messaging and meal reminders). Only athlete respondents were asked about motivators and barriers that influence meal choices. ``Health'' and ``sports performance'' were the highest scoring motivators, while the highest scoring barriers were ``cost of food,'' ``easy access to unhealthy food,'' and ``time to cook or prepare food.'' Notably, survey respondents provided positive feedback and interest using a novel function of the app: real-time meal feedback through food photography. Conclusions: The Eat2Win app is designed to combat RED-S and athlete malnutrition. Results from this study provide critical information on end-user opinions and preferences and will be used to further develop the Eat2Win app. Future research will aim to determine whether the Eat2Win app can prevent RED-S and the risk of athlete malnutrition to improve both health and performance. ", doi="10.2196/45098", url="https://formative.jmir.org/2023/1/e45098", url="http://www.ncbi.nlm.nih.gov/pubmed/37494083" } @Article{info:doi/10.2196/47098, author="Presseller, K. Emily and Lampe, W. Elizabeth and Zhang, Fengqing and Gable, A. Philip and Guetterman, C. Timothy and Forman, M. Evan and Juarascio, S. Adrienne", title="Using Wearable Passive Sensing to Predict Binge Eating in Response to Negative Affect Among Individuals With Transdiagnostic Binge Eating: Protocol for an Observational Study", journal="JMIR Res Protoc", year="2023", month="Jul", day="6", volume="12", pages="e47098", keywords="affect", keywords="binge eating", keywords="heart rate", keywords="heart rate variability", keywords="electrodermal activity", keywords="ecological momentary assessment", keywords="wearable sensors", keywords="ecological momentary intervention", abstract="Background: Binge eating (BE), characterized by eating a large amount of food accompanied by a sense of loss of control over eating, is a public health crisis. Negative affect is a well-established antecedent for BE. The affect regulation model of BE posits that elevated negative affect increases momentary risk for BE, as engaging in BE alleviates negative affect and reinforces the behavior. The eating disorder field's capacity to identify moments of elevated negative affect, and thus BE risk, has exclusively relied on ecological momentary assessment (EMA). EMA involves the completion of surveys in real time on one's smartphone to report behavioral, cognitive, and emotional symptoms throughout the day. Although EMA provides ecologically valid information, EMA surveys are often delivered only 5-6 times per day, involve self-report of affect intensity only, and are unable to assess affect-related physiological arousal. Wearable, psychophysiological sensors that measure markers of affect arousal including heart rate, heart rate variability, and electrodermal activity may augment EMA surveys to improve accurate real-time prediction of BE. These sensors can objectively and continuously measure biomarkers of nervous system arousal that coincide with affect, thus allowing them to measure affective trajectories on a continuous timescale, detect changes in negative affect before the individual is consciously aware of them, and reduce user burden to improve data completeness. However, it is unknown whether sensor features can distinguish between positive and negative affect states, given that physiological arousal may occur during both negative and positive affect states. Objective: The aims of this study are (1) to test the hypothesis that sensor features will distinguish positive and negative affect states in individuals with BE with >60\% accuracy and (2) test the hypothesis that a machine learning algorithm using sensor data and EMA-reported negative affect to predict the occurrence of BE will predict BE with greater accuracy than an algorithm using EMA-reported negative affect alone. Methods: This study will recruit 30 individuals with BE who will wear Fitbit Sense 2 wristbands to passively measure heart rate and electrodermal activity and report affect and BE on EMA surveys for 4 weeks. Machine learning algorithms will be developed using sensor data to distinguish instances of high positive and high negative affect (aim 1) and to predict engagement in BE (aim 2). Results: This project will be funded from November 2022 to October 2024. Recruitment efforts will be conducted from January 2023 through March 2024. Data collection is anticipated to be completed in May 2024. Conclusions: This study is anticipated to provide new insight into the relationship between negative affect and BE by integrating wearable sensor data to measure affective arousal. The findings from this study may set the stage for future development of more effective digital ecological momentary interventions for BE. International Registered Report Identifier (IRRID): DERR1-10.2196/47098 ", doi="10.2196/47098", url="https://www.researchprotocols.org/2023/1/e47098", url="http://www.ncbi.nlm.nih.gov/pubmed/37410522" } @Article{info:doi/10.2196/45184, author="Solans Noguero, David and Ram{\'i}rez-Cifuentes, Diana and R{\'i}ssola, Andr{\'e}s Esteban and Freire, Ana", title="Gender Bias When Using Artificial Intelligence to Assess Anorexia Nervosa on Social Media: Data-Driven Study", journal="J Med Internet Res", year="2023", month="Jun", day="8", volume="25", pages="e45184", keywords="anorexia nervosa", keywords="gender bias", keywords="artificial intelligence", keywords="social media", abstract="Background: Social media sites are becoming an increasingly important source of information about mental health disorders. Among them, eating disorders are complex psychological problems that involve unhealthy eating habits. In particular, there is evidence showing that signs and symptoms of anorexia nervosa can be traced in social media platforms. Knowing that input data biases tend to be amplified by artificial intelligence algorithms and, in particular, machine learning, these methods should be revised to mitigate biased discrimination in such important domains. Objective: The main goal of this study was to detect and analyze the performance disparities across genders in algorithms trained for the detection of anorexia nervosa on social media posts. We used a collection of automated predictors trained on a data set in Spanish containing cases of 177 users that showed signs of anorexia (471,262 tweets) and 326 control cases (910,967 tweets). Methods: We first inspected the predictive performance differences between the algorithms for male and female users. Once biases were detected, we applied a feature-level bias characterization to evaluate the source of such biases and performed a comparative analysis of such features and those that are relevant for clinicians. Finally, we showcased different bias mitigation strategies to develop fairer automated classifiers, particularly for risk assessment in sensitive domains. Results: Our results revealed concerning predictive performance differences, with substantially higher false negative rates (FNRs) for female samples (FNR=0.082) compared with male samples (FNR=0.005). The findings show that biological processes and suicide risk factors were relevant for classifying positive male cases, whereas age, emotions, and personal concerns were more relevant for female cases. We also proposed techniques for bias mitigation, and we could see that, even though disparities can be mitigated, they cannot be eliminated. Conclusions: We concluded that more attention should be paid to the assessment of biases in automated methods dedicated to the detection of mental health issues. This is particularly relevant before the deployment of systems that are thought to assist clinicians, especially considering that the outputs of such systems can have an impact on the diagnosis of people at risk. ", doi="10.2196/45184", url="https://www.jmir.org/2023/1/e45184", url="http://www.ncbi.nlm.nih.gov/pubmed/37289496" } @Article{info:doi/10.2196/40472, author="Melisse, Bernou and Berg, den Elske van and Jonge, de Margo and Blankers, Matthijs and Furth, van Eric and Dekker, Jack and Beurs, de Edwin", title="Efficacy of Web-Based, Guided Self-help Cognitive Behavioral Therapy--Enhanced for Binge Eating Disorder: Randomized Controlled Trial", journal="J Med Internet Res", year="2023", month="May", day="1", volume="25", pages="e40472", keywords="randomized controlled trial", keywords="RCT", keywords="binge eating disorder", keywords="BED", keywords="guided self-help", keywords="cognitive behavioral therapy--enhanced", keywords="CBT-E", abstract="Background: Owing to the gap between treatment supply and demand, there are long waiting periods for patients with binge eating disorder, and there is an urgent need to increase their access to specialized treatment. Guided self-help cognitive behavioral therapy--enhanced (CBT-E) may have great advantages for patients if its efficacy can be established. Objective: The aim of this study was to examine the efficacy of guided self-help CBT-E compared with that of a delayed-treatment control condition. Methods: A single-blind 2-arm randomized controlled trial was designed to evaluate guided self-help CBT-E according to an intention-to-treat analysis. A total of 180 patients were randomly assigned to guided self-help CBT-E (n=90, 50\%) or the delayed-treatment control condition (n=90, 50\%) for which guided self-help CBT-E was provided after the initial 12-week delay. The primary outcome was reduction in binges. The secondary outcome was full recovery at the end of treatment, as measured using the Eating Disorder Examination during the last 4 weeks of treatment. A linear mixed model analysis was performed to compare treatment outcomes at the end of treatment. A second linear mixed model analysis was performed to measure between- and within-group effects for up to 24 weeks of follow-up. The Eating Disorder Examination--Questionnaire and clinical impairment assessment were conducted before and after treatment and during follow-up. In addition, dropout rates were assessed in both conditions. Results: During the last 4 weeks of treatment, objective binges reduced from an average of 19 (SD 16) to 3 (SD 5) binges, and 40\% (36/90) showed full recovery in the guided self-help CBT-E group. Between-group effect size (Cohen d) was 1.0 for objective binges. At follow-up, after both groups received treatment, there was no longer a difference between the groups. Of the 180 participants, 142 (78.9\%) completed treatment. The overall treatment dropout appeared to be associated with gender, level of education, and number of objective binges at baseline but not with treatment condition. Conclusions: This is the first study to investigate the efficacy of guided self-help CBT-E. Guided self-help CBT-E appeared to be an efficacious treatment. This study's findings underscore the international guidelines recommending this type of treatment for binge eating disorder. Trial Registration: Netherlands Trial Registry (NTR) NL7994; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7994 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-020-02604-1 ", doi="10.2196/40472", url="https://www.jmir.org/2023/1/e40472", url="http://www.ncbi.nlm.nih.gov/pubmed/37126386" } @Article{info:doi/10.2196/40594, author="Guala, Mercedes Maria and Bul, Kim and Sk{\aa}rderud, Finn and S{\o}gaard Nielsen, Anette", title="A Serious Game for Patients With Eating Disorders (Maze Out): Pilot User Experience and Acceptance Study", journal="JMIR Form Res", year="2023", month="Jan", day="27", volume="7", pages="e40594", keywords="eating disorders", keywords="serious games", keywords="mHealth", keywords="coproduction", keywords="mobile health", keywords="mobile phone", abstract="Background: Eating disorders (EDs) are severe mental disorders associated with notable impairments in the quality of life. Despite the severity of the disorders and extensive research in the field, effective treatment for EDs is lacking. Digital interventions are gaining an evidence-based position in mental health, providing new perspectives in psychiatric treatment. Maze Out is a serious game coproduced by patients and therapists that focuses on supporting patients with EDs. Objective: The aim of this study was to investigate the experiences of engaging in and acceptability of Maze Out among patients with EDs and therapists. Methods: This study is a qualitative pilot study involving data collected through focus groups and individual interviews and user analytics collected through the game. The participants were recruited from the Odense Mental Health Service of the Region of Southern Denmark. Qualitative interviews analyzed by thematical analysis and interpreted by interpretative phenomenological analysis were used to evaluate the acceptance and experience of Maze Out among patients and therapists. The mobile health evidence reporting and assessment checklist was used to describe the content, context, and technical features of the game in a standardized manner for mobile health apps. Results: The participants found Maze Out to be engaging, easy to use, and a good platform for reflecting on their disorder. They primarily used Maze Out as a conversational tool with their close relationships, giving them insights into the experiences and daily life struggles of someone with EDs. Conclusions: Maze Out seems to be a promising tool supplementing the current ED treatment. Further research should focus on evaluating the effectiveness of the game and its potential to support patients with different types of EDs. ", doi="10.2196/40594", url="https://formative.jmir.org/2023/1/e40594", url="http://www.ncbi.nlm.nih.gov/pubmed/36705956" } @Article{info:doi/10.2196/38479, author="Juarascio, S. Adrienne and Srivastava, Paakhi and Presseller, K. Emily and Lin, Mandy and Patarinski, G. Anna G. and Manasse, M. Stephanie and Forman, M. Evan", title="Using Continuous Glucose Monitoring to Detect and Intervene on Dietary Restriction in Individuals With Binge Eating: The SenseSupport Withdrawal Design Study", journal="JMIR Form Res", year="2022", month="Dec", day="14", volume="6", number="12", pages="e38479", keywords="binge eating", keywords="loss-of-control eating", keywords="continuous glucose monitoring", keywords="mobile phone", abstract="Background: Dietary restraint is a key factor for maintaining engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a mechanism of change in cognitive behavioral therapy (CBT) for individuals with BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps owing to difficulty in using treatment skills (eg, regular eating) to reduce dietary restraint during their daily lives. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that uses continuous glucose monitoring to detect periods of dietary restraint, may improve CBT to reduce dietary restraint during treatment by providing real-time interventions. Objective: This study aimed to describe the feasibility, acceptability, and initial evaluation of SenseSupport. We presented feasibility, acceptability, target engagement, and initial treatment outcome data from a small trial using an ABAB (A=continuous glucose monitoring data sharing and JITAIs-Off, B=continuous glucose monitoring data sharing and JITAIs-On) design (in which JITAIs were turned on for 2 weeks and then turned off for 2 weeks throughout the treatment). Methods: Participants (N=30) were individuals with BED or BN engaging in ?3 episodes of ?5 hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform the delivery of JITAIs. Participants completed 4 assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment. Results: Retention was high (25/30, 83\% after treatment). However, the rates of continuous glucose monitoring data collection were low (67.4\% of expected glucose data were collected), and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was the desire for an empty stomach (t43=1.69; P=.049; Cohen d=0.25). There was also a trend toward greater decrease in overall restraint during JITAs-On periods compared with JITAIs-Off periods, but these results were not statistically significant (t43=1.60; P=.06; Cohen d=0.24). There was no significant difference in change in the frequency of binge eating during JITAIs-On periods compared with JITAIs-Off periods (P=.23). Participants demonstrated clinically significant, large decreases in binge eating (t24=10.36; P<.001; Cohen d=2.07), compensatory behaviors (t24=3.40; P=.001; Cohen d=0.68), and global eating pathology (t24=6.25; P<.001; Cohen d=1.25) from pre- to posttreatment. Conclusions: This study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs to augment CBT for binge-spectrum eating disorders. Despite the lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest that the SenseSupport system warrants additional investigation via future, fully powered clinical trials. Trial Registration: ClinicalTrials.gov NCT04126694; https://clinicaltrials.gov/ct2/show/NCT04126694 ", doi="10.2196/38479", url="https://formative.jmir.org/2022/12/e38479", url="http://www.ncbi.nlm.nih.gov/pubmed/36515992" } @Article{info:doi/10.2196/33813, author="Stoeten, Claudia and de Haan, Arnoud Hein and Postel, Gerda Marloes and Brusse-Keizer, Marjolein and ter Huurne, Dani{\"e}lle Elke", title="Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial", journal="JMIR Form Res", year="2022", month="Jun", day="30", volume="6", number="6", pages="e33813", keywords="therapeutic alliance", keywords="TA", keywords="treatment completion", keywords="cognitive behavioral therapy", keywords="CBT", keywords="web-CBT", keywords="eating disorders", abstract="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. ", doi="10.2196/33813", url="https://formative.jmir.org/2022/6/e33813", url="http://www.ncbi.nlm.nih.gov/pubmed/35771608" } @Article{info:doi/10.2196/31148, author="Drtilova, Hana and Machackova, Hana and Smahelova, Martina", title="Evaluation of Web-Based Health Information From the Perspective of Women With Eating Disorders: Thematic Analysis", journal="J Med Internet Res", year="2022", month="Jun", day="13", volume="24", number="6", pages="e31148", keywords="eating disorders", keywords="web-based health information", keywords="Czech women", abstract="Background: Users with experience of eating disorders use the internet as a source of information, whether for prorecovery activities (such as web-based treatment, looking for information, support, and sharing) or activities that promote eating disorder behavior as a desirable lifestyle choice (such as pro--eating disorder communities and reading and creating pro--eating disorder posts). Their assessment of web-based eating disorder--related information is crucial for understanding the context of the illness and for health professionals and their web-based interventions. Objective: This study aimed to understand the criteria young women with the experience of eating disorders use in evaluating eating disorder--related web-based information and what eating disorder--related characteristics of these women are involved in their evaluation. Methods: We analyzed 30 semistructured individual interviews with Czech women aged 16 to 28 years with past or present eating disorder experience using a qualitative approach. Thematic analysis was adopted as an analytical tool. Results: The specifics of eating disorder phases (the disorder stage and the treatment process) emerged as important aspects in the process of information assessment. Other specific characteristics of respondents (eg, motivation, abilities, and resources) addressed how the respondents arrived at certain web-based information and how they evaluated it. In addition, the respondents described some content cues as features of information (eg, novelty and social information pooling). Another finding is that other users' attitudes, experiences, activities, and personal features are involved in the information evaluation of these users and the information presented by them. Finally, the respondents evaluated the websites' visual look and graphic components. Conclusions: This study shows that web-based information evaluation reported by women with experience of eating disorders is a complex process. The assessment is influenced by current personal characteristics related to the illness (mainly the motivation for maintaining or curing the eating disorder) using cues associated with information content, other users, and website look. The study findings have important implications for health professionals, who should ask their clients questions about web-based communities and their needs to understand what information and sources they choose. ", doi="10.2196/31148", url="https://www.jmir.org/2022/6/e31148", url="http://www.ncbi.nlm.nih.gov/pubmed/35699984" } @Article{info:doi/10.2196/35947, author="Jacobi, Corinna and Vollert, Bianka and H{\"u}tter, Kristian and von Bloh, Paula and Eiterich, Nadine and G{\"o}rlich, Dennis and Taylor, Barr C.", title="Indicated Web-Based Prevention for Women With Anorexia Nervosa Symptoms: Randomized Controlled Efficacy Trial", journal="J Med Internet Res", year="2022", month="Jun", day="2", volume="24", number="6", pages="e35947", keywords="anorexia nervosa", keywords="internet", keywords="indicated prevention", abstract="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