TY - JOUR AU - Thomas, Carien Pamela AU - Bark, Pippa AU - Rowe, Sarah PY - 2025/5/6 TI - Exploring Therapists? Approaches to Treating Eating Disorders to Inform User-Centric App Design: Web-Based Interview Study JO - JMIR Form Res SP - e68846 VL - 9 KW - eating disorders KW - binge eating KW - bulimia KW - anorexia KW - qualitative research KW - mental health KW - smartphone apps KW - digital interventions KW - eHealth KW - mobile health KW - artificial intelligence N2 - 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. UR - https://formative.jmir.org/2025/1/e68846 UR - http://dx.doi.org/10.2196/68846 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/68846 ER - TY - JOUR AU - Blalock, V. Dan AU - Mehler, S. Philip AU - Michel, M. Deborah AU - Duffy, Alan AU - Le Grange, Daniel AU - O'Melia, M. Anne AU - Rienecke, D. Renee PY - 2025/5/2 TI - Virtual Versus In-Person Intensive Outpatient Treatment for Eating Disorders During the COVID-19 Pandemic in United States?Based Treatment Facilities: Naturalistic Study JO - J Med Internet Res SP - e66465 VL - 27 KW - eating disorders KW - virtual care KW - intensive outpatient KW - COVID-19 KW - higher level of care KW - depression KW - suicidal ideation KW - treatment KW - access KW - naturalistic N2 - 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. UR - https://www.jmir.org/2025/1/e66465 UR - http://dx.doi.org/10.2196/66465 UR - http://www.ncbi.nlm.nih.gov/pubmed/40314999 ID - info:doi/10.2196/66465 ER - TY - JOUR AU - Halicki-Asakawa, Amané AU - Mocci, Julia AU - Libben, Maya PY - 2025/4/10 TI - Mobile App?Delivered Motivational Interviewing for Women on Eating Disorder Treatment Waitlists (MI-Coach: ED): Protocol for an App Development and Pilot Evaluation JO - JMIR Res Protoc SP - e66298 VL - 14 KW - eating disorders KW - motivational interviewing KW - treatment barriers KW - digital interventions KW - pilot test KW - protocol KW - eating disorder KW - eating KW - woman KW - women KW - female KW - Canada KW - Canadian KW - mobile apps KW - mobile health KW - mHealth KW - app development KW - app-based KW - mental health KW - pilot evaluation KW - waitlists KW - mixed methods KW - feasibility KW - acceptability KW - service delivery N2 - 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 UR - https://www.researchprotocols.org/2025/1/e66298 UR - http://dx.doi.org/10.2196/66298 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/66298 ER - TY - JOUR AU - Keel, K. Pamela AU - Bodell, P. Lindsay AU - Ali, I. Sarrah AU - Starkey, Austin AU - Trotta, Jenna AU - Luxama, Woody J. AU - Halfhide, Chloé AU - Hill, G. Naomi AU - Appelbaum, Jonathan AU - Williams, L. Diana PY - 2025/4/8 TI - 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 JO - JMIR Res Protoc SP - e66554 VL - 14 KW - binge eating KW - weight suppression KW - leptin KW - glucagon-like peptide 1 KW - insulin KW - reward KW - satiation KW - longitudinal KW - behavior KW - Research Domain Criteria N2 - 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 UR - https://www.researchprotocols.org/2025/1/e66554 UR - http://dx.doi.org/10.2196/66554 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/66554 ER - TY - JOUR AU - Wang, Xiao AU - Xiao, Yuxue AU - Nam, Sujin AU - Zhong, Ting AU - Tang, Dongyan AU - Li, Cheung William Ho AU - Song, Peige AU - Xia, Wei PY - 2025/3/27 TI - Use of Mukbang in Health Promotion: Scoping Review JO - J Med Internet Res SP - e56147 VL - 27 KW - mukbang KW - health promotion KW - eating behaviors KW - appetite KW - scoping review N2 - 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/ UR - https://www.jmir.org/2025/1/e56147 UR - http://dx.doi.org/10.2196/56147 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56147 ER - TY - JOUR AU - Rooper, R. Isabel AU - Ortega, Adrian AU - Massion, A. Thomas AU - Lakhtakia, Tanvi AU - Kruger, Macarena AU - Parsons, M. Leah AU - Lipman, D. Lindsay AU - Azubuike, Chidiebere AU - Tack, Emily AU - Obleada, T. Katrina AU - Graham, K. Andrea PY - 2025/3/21 TI - Optimizing Testimonials for Behavior Change in a Digital Intervention for Binge Eating: Human-Centered Design Study JO - JMIR Form Res SP - e59691 VL - 9 KW - health behavior KW - health narratives KW - binge eating KW - user engagement KW - personalization KW - behavior change KW - digital health KW - intervention KW - human-centered design KW - behavioral health KW - preferences N2 - 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. UR - https://formative.jmir.org/2025/1/e59691 UR - http://dx.doi.org/10.2196/59691 ID - info:doi/10.2196/59691 ER - TY - JOUR AU - Schnepper, Rebekka AU - Roemmel, Noa AU - Schaefert, Rainer AU - Lambrecht-Walzinger, Lena AU - Meinlschmidt, Gunther PY - 2025/3/20 TI - 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 JO - JMIR Ment Health SP - e57986 VL - 12 KW - anorexia nervosa KW - artificial intelligence KW - bulimia nervosa KW - ChatGPT KW - eating disorders KW - LLM KW - responsible AI KW - transformer KW - bias KW - large language model KW - gender KW - vignette KW - quality of life KW - symptomatology KW - questionnaire KW - generative AI KW - mental health KW - AI N2 - 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 × 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. UR - https://mental.jmir.org/2025/1/e57986 UR - http://dx.doi.org/10.2196/57986 ID - info:doi/10.2196/57986 ER - TY - JOUR AU - Gulec, Hayriye AU - Muzik, Michal AU - Smahel, David AU - Dedkova, Lenka PY - 2025/3/11 TI - Longitudinal Associations Between Adolescents? mHealth App Use, Body Dissatisfaction, and Physical Self-Worth: Random Intercept Cross-Lagged Panel Study JO - JMIR Ment Health SP - e60844 VL - 12 KW - mHealth app KW - body dissatisfaction KW - physical self-worth KW - random intercept cross-lagged panel model KW - RI-CLPM KW - longitudinal study KW - adolescent N2 - 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 (?=.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 (?=.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. UR - https://mental.jmir.org/2025/1/e60844 UR - http://dx.doi.org/10.2196/60844 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60844 ER - TY - JOUR AU - Miranda, Christina AU - Matheson, Brittany AU - Datta, Nandini AU - Whyte, Aileen AU - Yang, Hyun-Joon AU - Schmiedmayer, Paul AU - Ravi, Vishnu AU - Aalami, Oliver AU - Lock, James PY - 2025/2/28 TI - Enhancing Distress Tolerance Skills in Adolescents With Anorexia Nervosa Through the BALANCE Mobile App: Feasibility and Acceptability Study JO - JMIR Form Res SP - e70278 VL - 9 KW - mHealth KW - mobile health KW - mobile application KW - emotion regulation KW - eating disorders KW - family-based treatment KW - distress tolerance KW - mealtimes N2 - 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. UR - https://formative.jmir.org/2025/1/e70278 UR - http://dx.doi.org/10.2196/70278 ID - info:doi/10.2196/70278 ER - TY - JOUR AU - Cheung, Gar-Mun Lauryn AU - Thomas, Carien Pamela AU - Brvar, Eva AU - Rowe, Sarah PY - 2025/1/3 TI - User Experiences of and Preferences for Self-Guided Digital Interventions for the Treatment of Mild to Moderate Eating Disorders: Systematic Review and Metasynthesis JO - JMIR Ment Health SP - e57795 VL - 12 KW - eating disorders KW - anorexia KW - bulimia KW - binge eating KW - other specified feeding or eating disorder KW - OSFED KW - intervention KW - digital intervention KW - self-help KW - systematic review N2 - 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 UR - https://mental.jmir.org/2025/1/e57795 UR - http://dx.doi.org/10.2196/57795 UR - http://www.ncbi.nlm.nih.gov/pubmed/39752210 ID - info:doi/10.2196/57795 ER - TY - JOUR AU - Palacios, E. Jorge AU - Erickson-Ridout, K. Kathryn AU - Paik Kim, Jane AU - Buttlaire, Stuart AU - Ridout, Samuel AU - Argue, Stuart AU - Tregarthen, Jenna PY - 2024/11/27 TI - 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 JO - JMIR Ment Health SP - e59145 VL - 11 KW - digital therapeutics KW - app-augmented therapy KW - eating disorders KW - health care utilization KW - costs KW - real-world data KW - depression KW - emergency department KW - outpatient care KW - eating KW - treatment KW - therapy KW - retrospective analysis KW - electronic health record KW - patient KW - app KW - outpatient N2 - 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. UR - https://mental.jmir.org/2024/1/e59145 UR - http://dx.doi.org/10.2196/59145 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59145 ER - TY - JOUR AU - Liu, Jianyi AU - Giannone, Alyssa AU - Wang, Hailing AU - Wetherall, Lucy AU - Juarascio, Adrienne PY - 2024/11/18 TI - Understanding Patients? Preferences for a Digital Intervention to Prevent Posttreatment Deterioration for Bulimia-Spectrum Eating Disorders: User-Centered Design Study JO - JMIR Form Res SP - e60865 VL - 8 KW - bulimia nervosa KW - binge eating KW - digital intervention KW - deterioration prevention KW - eating disorder KW - bulimia KW - digital health KW - deterioration KW - maintenance KW - mHealth KW - mobile health app KW - interviews KW - qualitative KW - user-centered design KW - psychotherapy KW - CBT KW - cognitive behavioral therapy KW - needs KW - preferences KW - mobile phone N2 - 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. UR - https://formative.jmir.org/2024/1/e60865 UR - http://dx.doi.org/10.2196/60865 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60865 ER - TY - JOUR AU - Oliveira, Ashleigh AU - Wolff, John AU - Alfouzan, Nouf AU - Yu, Jin AU - Yahya, Asma AU - Lammy, Kayla AU - Nakamura, T. Manabu PY - 2024/11/11 TI - A Novel Web App for Dietary Weight Management: Development, Implementation, and Usability Study JO - JMIR Form Res SP - e58363 VL - 8 KW - health application KW - weight loss KW - behavior change technique KW - BCT KW - online weight loss program KW - weight monitoring KW - meal planning KW - sustainable weight loss KW - dietary fiber KW - mHealth KW - mobile health N2 - 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. UR - https://formative.jmir.org/2024/1/e58363 UR - http://dx.doi.org/10.2196/58363 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58363 ER - TY - JOUR AU - Gentile, Alessandra AU - Kristian, Yan Yosua AU - Cini, Erica PY - 2024/11/4 TI - Effectiveness of Computer-Based Psychoeducational Self-Help Platforms for Eating Disorders (With or Without an Associated App): Protocol for a Systematic Review JO - JMIR Res Protoc SP - e60165 VL - 13 KW - self-help KW - online self-help KW - eating disorders KW - anorexia nervosa KW - psychoeducational intervention KW - psychoeducation KW - binge eating KW - anorexia KW - bulimia KW - access to care KW - patient education KW - patient self-help N2 - 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 (± 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 ± associated apps intervention clinical outcome of ED symptoms; pre? and post?computer-based ± 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 ± 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 UR - https://www.researchprotocols.org/2024/1/e60165 UR - http://dx.doi.org/10.2196/60165 UR - http://www.ncbi.nlm.nih.gov/pubmed/39495557 ID - info:doi/10.2196/60165 ER - TY - JOUR AU - Thomas, Carien Pamela AU - Curtis, Kristina AU - Potts, W. Henry W. AU - Bark, Pippa AU - Perowne, Rachel AU - Rookes, Tasmin AU - Rowe, Sarah PY - 2024/8/1 TI - Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis JO - JMIR Ment Health SP - e57577 VL - 11 KW - digital health KW - eHealth KW - mobile health KW - mHealth KW - mobile apps KW - smartphone KW - behavior change KW - behavior change technique KW - systematic review KW - eating disorders KW - disordered eating KW - binge eating KW - bulimia nervosa KW - mobile phone N2 - 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: ?21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results. Conclusions: There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions. Trial Registration: PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060 UR - https://mental.jmir.org/2024/1/e57577 UR - http://dx.doi.org/10.2196/57577 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57577 ER - TY - JOUR AU - Faccio, Elena AU - Reggiani, Margherita AU - Rocelli, Michele AU - Cipolletta, Sabrina PY - 2024/7/2 TI - Issues Related to the Use of Visual Social Networks and Perceived Usefulness of Social Media Literacy During the Recovery Phase: Qualitative Research Among Girls With Eating Disorders JO - J Med Internet Res SP - e53334 VL - 26 KW - visual social networks KW - body image KW - eating disorders KW - risks KW - potentials KW - social networks KW - social network KW - social media KW - literacy KW - food intake KW - appetite disorders KW - appetite disorder KW - eating disorder KW - patient safety KW - patient-centered approach KW - recovery KW - body comparison KW - users KW - semistructured interviews KW - semistructured interview KW - girls KW - adolescent KW - adolescents KW - content analysis KW - online N2 - Background: The patient-centered approach is essential for quality health care and patient safety. Understanding the service user?s perspective on the factors maintaining the health problem is crucial for successful treatment, especially for patients who do not recognize their condition as clinically relevant or concerning. Despite the association between intensive use of visual social media and body dissatisfaction and eating disorders, little is known about the meanings users assign to posting or searching for edited photos and the strategies they use to protect themselves from digital risks. Objective: This study aims to examine how young women recovering from eating disorders in Northern Italy perceive the health risks and potential benefits associated with visual social networks (ie, Instagram and Snapchat). The literature has found these platforms to be detrimental to online body comparisons. It also explores the perceived usefulness, willingness, and personal interest in coconstructing social media literacy programs with girls recovering from eating disorders. Methods: A total of 30 semistructured interviews were conducted with adolescent girls aged 14-17 years at the end of their treatment for eating disorders. The following areas of research were addressed: (1) the meanings associated with the use of Instagram and Snapchat; (2) the investment in the photographic dimension and feedback; (3) the impact of visual social networks on body experiences; (4) the potential and risks perceived in their use; (5) the importance of supporting girls undergoing treatment for eating disorders in using social networks; and (6) the usefulness and willingness to co-design social network literacy programs. Content analysis was applied. Results: A total of 7 main contents emerged: active or passive role in using social networks, the impact of online interactions on body image, investment in the photographic dimension, effects on self-representation, perceived risks, self-protective strategies, and potential benefits. The findings highlight a strong awareness of the processes that trigger body comparisons in the virtual context, creating insecurity and worsening the relationship with oneself. The self-protective behaviors identified are the development of critical thinking, the avoidance of sensitive content, increased control over social networking site use, and a certain skepticism toward developing antagonistic ideologies. All these topics were considered fundamental. Conclusions: The findings provide important insights for health professionals working with youth in preparing media literacy programs. These programs aim to reduce potential risks and amplify the positive effects of online resources. They underscore the importance of addressing this issue during hospitalization to develop skills and critical thinking aimed at changing small habits that perpetuate the problem in everyday life. The inherent limitations in current service practices, which may not adequately address individual needs or impact posttreatment life, must also be considered. UR - https://www.jmir.org/2024/1/e53334 UR - http://dx.doi.org/10.2196/53334 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/53334 ER - TY - JOUR AU - Pare, M. Shannon AU - Gunn, Elizabeth AU - Morrison, M. Katherine AU - Miller, L. Alison AU - Duncan, M. Alison AU - Buchholz, C. Andrea AU - Ma, L. David W. AU - Tremblay, F. Paul AU - Vallis, Ann Lori AU - Mercer, J. Nicola AU - Haines, Jess PY - 2024/6/20 TI - Testing a Biobehavioral Model of Chronic Stress and Weight Gain in Young Children (Family Stress Study): Protocol and Baseline Demographics for a Prospective Observational Study JO - JMIR Res Protoc SP - e48549 VL - 13 KW - stress KW - child, preschool KW - adiposity KW - household chaos KW - cortisol KW - COVID-19 KW - behavioral mechanisms KW - caregiver-child relationship quality N2 - Background: Chronic stress is an important risk factor in the development of obesity. While research suggests chronic stress is linked to excess weight gain in children, the biological or behavioral mechanisms are poorly understood. Objective: The objectives of the Family Stress Study are to examine behavioral and biological pathways through which chronic stress exposure (including stress from COVID-19) may be associated with adiposity in young children, and to determine if factors such as child sex, caregiver-child relationship quality, caregiver education, and caregiver self-regulation moderate the association between chronic stress and child adiposity. Methods: The Family Stress Study is a prospective cohort study of families recruited from 2 Canadian sites: the University of Guelph in Guelph, Ontario, and McMaster University in Hamilton, Ontario. Participants will be observed for 2 years and were eligible to participate if they had at least one child (aged 2-6 years) and no plans to move from the area within the next 3 years. Study questionnaires and measures were completed remotely at baseline and will be assessed using the same methods at 1- and 2-year follow-ups. At each time point, caregivers measure and report their child?s height, weight, and waist circumference, collect a hair sample for cortisol analysis, and fit their child with an activity monitor to assess the child?s physical activity and sleep. Caregivers also complete a web-based health and behaviors survey with questions about family demographics, family stress, their own weight-related behaviors, and their child?s mental health, as well as a 1-day dietary assessment for their child. Results: Enrollment for this study was completed in December 2021. The final second-year follow-up was completed in April 2024. This study?s sample includes 359 families (359 children, 359 female caregivers, and 179 male caregivers). The children?s mean (SD) age is 3.9 years (1.2 years) and 51% (n=182) are female. Approximately 74% (n=263) of children and 80% (n=431) of caregivers identify as White. Approximately 34% (n=184) of caregivers have a college diploma or less and nearly 93% (n=499) are married or cohabiting with a partner. Nearly half (n=172, 47%) of the families have an annual household income ?CAD $100,000 (an average exchange rate of 1 CAD=0.737626 USD applies). Data cleaning and analysis are ongoing as of manuscript publication. Conclusions: Despite public health restrictions from COVID-19, the Family Stress Study was successful in recruiting and using remote data collection to successfully engage families in this study. The results from this study will help identify the direction and relative contributions of the biological and behavioral pathways linking chronic stress and adiposity. These findings will aid in the development of effective interventions designed to modify these pathways and reduce obesity risk in children. Trial Registration: ClinicalTrials.gov NCT05534711; https://clinicaltrials.gov/study/NCT05534711 International Registered Report Identifier (IRRID): DERR1-10.2196/48549 UR - https://www.researchprotocols.org/2024/1/e48549 UR - http://dx.doi.org/10.2196/48549 UR - http://www.ncbi.nlm.nih.gov/pubmed/38900565 ID - info:doi/10.2196/48549 ER - TY - JOUR AU - Bould, Helen AU - Kennedy, Mari-Rose AU - Penton-Voak, Ian AU - Thomas, May Lisa AU - Bird, Jon AU - Biddle, Lucy PY - 2024/5/14 TI - Exploring How Virtual Reality Could Be Used to Treat Eating Disorders: Qualitative Study of People With Eating Disorders and Clinicians Who Treat Them JO - JMIR XR Spatial Comput SP - e47382 VL - 1 KW - eating disorders KW - virtual reality KW - anorexia nervosa KW - bulimia nervosa KW - EDNOS KW - treatment KW - immersive KW - clinicians KW - qualitative data KW - psychoeducation KW - therapeutic KW - limitations N2 - 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. UR - https://xr.jmir.org/2024/1/e47382 UR - http://dx.doi.org/10.2196/47382 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/47382 ER - TY - JOUR AU - Lim, Heemoon AU - Lee, Hyejung PY - 2024/4/5 TI - Eating Habits and Lifestyle Factors Related to Childhood Obesity Among Children Aged 5-6 Years: Cluster Analysis of Panel Survey Data in Korea JO - JMIR Public Health Surveill SP - e51581 VL - 10 KW - BMI KW - body mass index KW - childhood obesity KW - cluster analysis KW - healthy eating KW - healthy lifestyle KW - pediatric obesity KW - preschool child KW - prevention KW - unsupervised machine learning N2 - 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. UR - https://publichealth.jmir.org/2024/1/e51581 UR - http://dx.doi.org/10.2196/51581 UR - http://www.ncbi.nlm.nih.gov/pubmed/38578687 ID - info:doi/10.2196/51581 ER - TY - JOUR AU - Anastasiadou, Dimitra AU - Herrero, Pol AU - Garcia-Royo, Paula AU - Vázquez-De Sebastián, Julia AU - Slater, Mel AU - Spanlang, Bernhard AU - Álvarez de la Campa, Elena AU - Ciudin, Andreea AU - Comas, Marta AU - Ramos-Quiroga, Antoni Josep AU - Lusilla-Palacios, Pilar PY - 2024/4/5 TI - Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial JO - J Med Internet Res SP - e51558 VL - 26 KW - obesity KW - virtual reality KW - psychological treatment KW - embodiment KW - motivational interviewing KW - self-conversation N2 - 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 (?=?.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG (?=?.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating (?=.71; P=.01) and emotional eating (?=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants (?=.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 UR - https://www.jmir.org/2024/1/e51558 UR - http://dx.doi.org/10.2196/51558 UR - http://www.ncbi.nlm.nih.gov/pubmed/38578667 ID - info:doi/10.2196/51558 ER - TY - JOUR AU - Edwards, Katie AU - Croker, Helen AU - Farrow, Claire AU - Haycraft, Emma AU - Herle, Moritz AU - Llewellyn, Clare AU - Pickard, Abigail AU - Blissett, Jacqueline PY - 2024/3/19 TI - 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 JO - JMIR Res Protoc SP - e55193 VL - 13 KW - ecological momentary assessment KW - avid eating KW - children?s eating behavior KW - parental feeding practices KW - feeding behaviour KW - parent KW - children KW - eating behaviour KW - obesity KW - environmental factors KW - observational study KW - feeding KW - United Kingdom N2 - 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 UR - https://www.researchprotocols.org/2024/1/e55193 UR - http://dx.doi.org/10.2196/55193 UR - http://www.ncbi.nlm.nih.gov/pubmed/38502178 ID - info:doi/10.2196/55193 ER - TY - JOUR AU - O'Hara, Cathal AU - Gibney, R. Eileen PY - 2024/2/14 TI - Dietary Intake Assessment Using a Novel, Generic Meal?Based Recall and a 24-Hour Recall: Comparison Study JO - J Med Internet Res SP - e48817 VL - 26 KW - meal patterns KW - eating behaviors KW - eating occasions KW - nutrition assessment KW - dietary intake assessment KW - 24-hour recall KW - relative validity N2 - 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. UR - https://www.jmir.org/2024/1/e48817 UR - http://dx.doi.org/10.2196/48817 UR - http://www.ncbi.nlm.nih.gov/pubmed/38354039 ID - info:doi/10.2196/48817 ER - TY - JOUR AU - Huffman, Goodgame Landry AU - Lawrence-Sidebottom, Darian AU - Beam, Brenna Aislinn AU - Parikh, Amit AU - Guerra, Rachael AU - Roots, Monika AU - Huberty, Jennifer PY - 2024/1/31 TI - Improvements in Adolescents? Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study JO - JMIR Form Res SP - e54253 VL - 8 KW - behavioral care KW - mental health KW - web-based coaching KW - web-based therapy KW - eating disorders KW - eating KW - anorexia KW - coach KW - coaching KW - pediatric KW - pediatrics KW - adolescent KW - adolescents KW - teen KW - teens KW - teenager KW - teenagers KW - digital mental health intervention KW - DMHI KW - collaborative KW - digital health N2 - 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. UR - https://formative.jmir.org/2024/1/e54253 UR - http://dx.doi.org/10.2196/54253 UR - http://www.ncbi.nlm.nih.gov/pubmed/38294855 ID - info:doi/10.2196/54253 ER - TY - JOUR AU - Myers, A. Candice AU - Beyl, A. Robbie AU - Hsia, S. Daniel AU - Harris, N. Melissa AU - Reed, J. Isabella AU - Eliser, D. Danielle AU - Bagneris, Lauren AU - Apolzan, W. John PY - 2023/12/20 TI - Effects of Episodic Food Insecurity on Psychological and Physiological Responses in African American Women With Obesity (RESPONSES): Protocol for a Longitudinal Observational Cohort Study JO - JMIR Res Protoc SP - e52193 VL - 12 KW - food security KW - body weight KW - racially minoritized group KW - low income KW - stress KW - cortisol KW - allostatic load N2 - 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 UR - https://www.researchprotocols.org/2023/1/e52193 UR - http://dx.doi.org/10.2196/52193 UR - http://www.ncbi.nlm.nih.gov/pubmed/38117554 ID - info:doi/10.2196/52193 ER - TY - JOUR AU - Bond, S. Dale AU - Papasavas, K. Pavlos AU - Raynor, A. Hollie AU - Grilo, M. Carlos AU - Steele, R. Vaughn PY - 2023/11/6 TI - 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 JO - JMIR Res Protoc SP - e50714 VL - 12 KW - obesity KW - repetitive transcranial magnetic stimulation KW - food reinforcement KW - hedonic hunger KW - electroencephalography KW - metabolic and bariatric surgery N2 - 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 UR - https://www.researchprotocols.org/2023/1/e50714 UR - http://dx.doi.org/10.2196/50714 UR - http://www.ncbi.nlm.nih.gov/pubmed/37930756 ID - info:doi/10.2196/50714 ER - TY - JOUR AU - Sun, Shufang AU - Nardi, William AU - Murphy, Matthew AU - Scott, Ty AU - Saadeh, Frances AU - Roy, Alexandra AU - Brewer, Judson PY - 2023/9/26 TI - Mindfulness-Based Mobile Health to Address Unhealthy Eating Among Middle-Aged Sexual Minority Women With Early Life Adversity: Mixed Methods Feasibility Trial JO - J Med Internet Res SP - e46310 VL - 25 KW - mobile health KW - mindfulness KW - obesity KW - sexual minority women KW - early life adversity KW - cell phone KW - mobile phone N2 - 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. UR - https://www.jmir.org/2023/1/e46310 UR - http://dx.doi.org/10.2196/46310 UR - http://www.ncbi.nlm.nih.gov/pubmed/37751273 ID - info:doi/10.2196/46310 ER - TY - JOUR AU - Hamatani, Sayo AU - Matsumoto, Kazuki AU - Andersson, Gerhard AU - Tomioka, Yukiko AU - Numata, Shusuke AU - Kamashita, Rio AU - Sekiguchi, Atsushi AU - Sato, Yasuhiro AU - Fukudo, Shin AU - Sasaki, Natsuki AU - Nakamura, Masayuki AU - Otani, Ryoko AU - Sakuta, Ryoichi AU - Hirano, Yoshiyuki AU - Kosaka, Hirotaka AU - Mizuno, Yoshifumi PY - 2023/9/19 TI - Guided Internet-Based Cognitive Behavioral Therapy for Women With Bulimia Nervosa: Protocol for a Multicenter Randomized Controlled Trial JO - JMIR Res Protoc SP - e49828 VL - 12 KW - bulimia nervosa KW - internet-based cognitive behavioral therapy KW - ICBT KW - randomized controlled trial KW - RCT KW - protocol KW - randomized KW - controlled trial KW - bulimia KW - eating KW - cognitive behavioral therapy KW - CBT KW - binge eating KW - purging KW - mobile phone N2 - 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 UR - https://www.researchprotocols.org/2023/1/e49828 UR - http://dx.doi.org/10.2196/49828 UR - http://www.ncbi.nlm.nih.gov/pubmed/37725414 ID - info:doi/10.2196/49828 ER - TY - JOUR AU - Woo, Sarah AU - Jung, Sunho AU - Lim, Hyunjung AU - Kim, YoonMyung AU - Park, Hee Kyung PY - 2023/8/17 TI - Exploring the Effect of the Dynamics of Behavioral Phenotypes on Health Outcomes in an mHealth Intervention for Childhood Obesity: Longitudinal Observational Study JO - J Med Internet Res SP - e45407 VL - 25 KW - behavioral dynamics KW - behavioral phenotype KW - functional data analysis KW - FDA KW - machine learning analysis KW - mobile health KW - mHealth KW - obesity intervention KW - pediatric obesity KW - mobile phone N2 - 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 (?=?.0766, 95% CI ?.1245 to ?.0312), fruit and vegetable intake (?=.1770, 95% CI .0642-.2561), exercise (?=?.0711, 95% CI ?.0892 to ?.0363), drinking water (?=?.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 (?=.0440, 95% CI .0186-.0550), fruit and vegetable intake (?=?.1177, 95% CI ?.1441 to ?.0680), and sleep duration (?=?.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 UR - https://www.jmir.org/2023/1/e45407 UR - http://dx.doi.org/10.2196/45407 UR - http://www.ncbi.nlm.nih.gov/pubmed/37590040 ID - info:doi/10.2196/45407 ER - TY - JOUR AU - Sharp, Gemma AU - Torous, John AU - West, L. Madeline PY - 2023/8/14 TI - Ethical Challenges in AI Approaches to Eating Disorders JO - J Med Internet Res SP - e50696 VL - 25 KW - eating disorders KW - body image KW - artificial intelligence KW - AI KW - chatbot KW - ethics UR - https://www.jmir.org/2023/1/e50696 UR - http://dx.doi.org/10.2196/50696 UR - http://www.ncbi.nlm.nih.gov/pubmed/37578836 ID - info:doi/10.2196/50696 ER - TY - JOUR AU - Glympi, Alkyoni AU - Odegi, Dorothy AU - Zandian, Modjtaba AU - Södersten, Per AU - Bergh, Cecilia AU - Langlet, Billy PY - 2023/8/10 TI - Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study JO - JMIR Serious Games SP - e44348 VL - 11 KW - exposure therapy KW - eating behavior KW - anorexia nervosa KW - bulimia nervosa KW - binge eating disorder KW - overweight KW - obesity KW - immersive virtual reality KW - VR KW - virtual reality N2 - Background: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. Objective: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. Methods: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. Results: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=?5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. Conclusions: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. Trial Registration: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209 UR - https://games.jmir.org/2023/1/e44348 UR - http://dx.doi.org/10.2196/44348 UR - http://www.ncbi.nlm.nih.gov/pubmed/37561558 ID - info:doi/10.2196/44348 ER - TY - JOUR AU - Amiri, Maryam AU - Li, Juan AU - Hasan, Wordh PY - 2023/8/3 TI - Personalized Flexible Meal Planning for Individuals With Diet-Related Health Concerns: System Design and Feasibility Validation Study JO - JMIR Form Res SP - e46434 VL - 7 KW - diabetes KW - fuzzy logic KW - meal planning KW - multicriteria decision-making KW - optimization N2 - Background: Chronic diseases such as heart disease, stroke, diabetes, and hypertension are major global health challenges. Healthy eating can help people with chronic diseases manage their condition and prevent complications. However, making healthy meal plans is not easy, as it requires the consideration of various factors such as health concerns, nutritional requirements, tastes, economic status, and time limits. Therefore, there is a need for effective, affordable, and personalized meal planning that can assist people in choosing food that suits their individual needs and preferences. Objective: This study aimed to design an artificial intelligence (AI)?powered meal planner that can generate personalized healthy meal plans based on the user?s specific health conditions, personal preferences, and status. Methods: We proposed a system that integrates semantic reasoning, fuzzy logic, heuristic search, and multicriteria analysis to produce flexible, optimized meal plans based on the user?s health concerns, nutrition needs, as well as food restrictions or constraints, along with other personal preferences. Specifically, we constructed an ontology-based knowledge base to model knowledge about food and nutrition. We defined semantic rules to represent dietary guidelines for different health concerns and built a fuzzy membership of food nutrition based on the experience of experts to handle vague and uncertain nutritional data. We applied a semantic rule-based filtering mechanism to filter out food that violate mandatory health guidelines and constraints, such as allergies and religion. We designed a novel, heuristic search method that identifies the best meals among several candidates and evaluates them based on their fuzzy nutritional score. To select nutritious meals that also satisfy the user?s other preferences, we proposed a multicriteria decision-making approach. Results: We implemented a mobile app prototype system and evaluated its effectiveness through a use case study and user study. The results showed that the system generated healthy and personalized meal plans that considered the user?s health concerns, optimized nutrition values, respected dietary restrictions and constraints, and met the user?s preferences. The users were generally satisfied with the system and its features. Conclusions: We designed an AI-powered meal planner that helps people create healthy and personalized meal plans based on their health conditions, preferences, and status. Our system uses multiple techniques to create optimized meal plans that consider multiple factors that affect food choice. Our evaluation tests confirmed the usability and feasibility of the proposed system. However, some limitations such as the lack of dynamic and real-time updates should be addressed in future studies. This study contributes to the development of AI-powered personalized meal planning systems that can support people?s health and nutrition goals. UR - https://formative.jmir.org/2023/1/e46434 UR - http://dx.doi.org/10.2196/46434 UR - http://www.ncbi.nlm.nih.gov/pubmed/37535413 ID - info:doi/10.2196/46434 ER - TY - JOUR AU - Mey, T. Jacob AU - Karpinski, A. Christine AU - Yang, Shengping AU - Madere, D. Joseph AU - Piattoly, Tavis AU - Harper, Ronnie AU - Kirwan, P. John PY - 2023/7/26 TI - 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 JO - JMIR Form Res SP - e45098 VL - 7 KW - dietitian KW - malnutrition KW - mHealth KW - mobile health KW - performance KW - RED-S KW - relative energy deficiency in sport KW - sports nutrition KW - technology N2 - 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. UR - https://formative.jmir.org/2023/1/e45098 UR - http://dx.doi.org/10.2196/45098 UR - http://www.ncbi.nlm.nih.gov/pubmed/37494083 ID - info:doi/10.2196/45098 ER - TY - JOUR AU - Presseller, K. Emily AU - Lampe, W. Elizabeth AU - Zhang, Fengqing AU - Gable, A. Philip AU - Guetterman, C. Timothy AU - Forman, M. Evan AU - Juarascio, S. Adrienne PY - 2023/7/6 TI - Using Wearable Passive Sensing to Predict Binge Eating in Response to Negative Affect Among Individuals With Transdiagnostic Binge Eating: Protocol for an Observational Study JO - JMIR Res Protoc SP - e47098 VL - 12 KW - affect KW - binge eating KW - heart rate KW - heart rate variability KW - electrodermal activity KW - ecological momentary assessment KW - wearable sensors KW - ecological momentary intervention N2 - 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 UR - https://www.researchprotocols.org/2023/1/e47098 UR - http://dx.doi.org/10.2196/47098 UR - http://www.ncbi.nlm.nih.gov/pubmed/37410522 ID - info:doi/10.2196/47098 ER - TY - JOUR AU - Solans Noguero, David AU - Ramírez-Cifuentes, Diana AU - Ríssola, Andrés Esteban AU - Freire, Ana PY - 2023/6/8 TI - Gender Bias When Using Artificial Intelligence to Assess Anorexia Nervosa on Social Media: Data-Driven Study JO - J Med Internet Res SP - e45184 VL - 25 KW - anorexia nervosa KW - gender bias KW - artificial intelligence KW - social media N2 - 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. UR - https://www.jmir.org/2023/1/e45184 UR - http://dx.doi.org/10.2196/45184 UR - http://www.ncbi.nlm.nih.gov/pubmed/37289496 ID - info:doi/10.2196/45184 ER - TY - JOUR AU - Guala, Mercedes Maria AU - Bul, Kim AU - Skårderud, Finn AU - Søgaard Nielsen, Anette PY - 2023/1/27 TI - A Serious Game for Patients With Eating Disorders (Maze Out): Pilot User Experience and Acceptance Study JO - JMIR Form Res SP - e40594 VL - 7 KW - eating disorders KW - serious games KW - mHealth KW - coproduction KW - mobile health KW - mobile phone N2 - 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. UR - https://formative.jmir.org/2023/1/e40594 UR - http://dx.doi.org/10.2196/40594 UR - http://www.ncbi.nlm.nih.gov/pubmed/36705956 ID - info:doi/10.2196/40594 ER - TY - JOUR AU - Hellner, Megan AU - Steinberg, Dori AU - Baker, H. Jessica AU - Blanton, Camilla PY - 2023/1/26 TI - Digitally Delivered Dietary Interventions for Patients with Eating Disorders Undergoing Family-Based Treatment: Protocol for a Randomized Feasibility Trial JO - JMIR Res Protoc SP - e41837 VL - 12 KW - eating disorders KW - virtual treatment KW - dietary interventions KW - family-based treatment KW - anorexia KW - psychiatric disorder KW - digital health intervention KW - telehealth KW - virtual health N2 - Background: Eating disorders (EDs) affect 9% of the United States population, and anorexia nervosa (AN), specifically, has the second highest mortality rate of all psychiatric disorders. Yet, only 20% are able to access treatment. Access to care issues include long waitlists, lack of trained specialists, financial, and geographic barriers, all of which highlight the need for effective telehealth interventions. Family-based therapy (FBT) is a first-line treatment for adolescents and young adults with EDs, and weight gain early in treatment is considered a primary predictor of success with FBT. However, nutrition requirements for patients with EDs are uniquely complex. A variety of dietary interventions for guiding the renourishment process are used in practice, but empirical data on the effectiveness and acceptability of the various interventions are sparse. The significance of nutritional restoration and issues with access to first-line treatments underscore the need for further research exploring virtually delivered dietary interventions. Objective: Our objective is to compare the effectiveness and acceptability of 2 digitally delivered dietary interventions frequently used in eating disorder treatment settings: (1) calorie-based meal plans and (2) the Plate-by-Plate approach. Specifically, we will explore any potential differences in weight restoration achieved over 8 weeks of treatment as a primary measure of effectiveness, as well as additional treatment outcomes (ED symptoms, anxiety, depression, caregiver burden, and perceived effectiveness and acceptability for both caregivers and clinicians). Methods: Patients (N=100) with either AN or avoidant restrictive food intake disorders (ARFID) aged 6-24 years seeking treatment at a nationwide virtual eating disorder treatment program, were enrolled between May and August 2022. Upon admission, patients were randomly assigned to receive either the calorie-based intervention or Plate-by-Plate approach from their registered dietitian, all of whom have received training as study interventionists. While we were primarily interested in responses during the first 8 weeks of treatment, patients will be followed for up to 12 months. Descriptive statistics were used to describe patient characteristics and demographics. Weight changes and other treatment outcomes between groups will be compared using generalized linear models. Semistructured caregiver and clinician interview transcripts will undergo qualitative analysis. Results: Enrollment ran from March to August 2022, and we anticipate completion of data collection by November 2022. Analyses will be completed in January 2023. Conclusions: This study contributes to existing FBT literature by thoroughly exploring the acceptability of dietary interventions and their influence on weight restoration, an area in which research is sparse. International Registered Report Identifier (IRRID): DERR1-10.2196/41837 UR - https://www.researchprotocols.org/2023/1/e41837 UR - http://dx.doi.org/10.2196/41837 UR - http://www.ncbi.nlm.nih.gov/pubmed/36701182 ID - info:doi/10.2196/41837 ER - TY - JOUR AU - Jarman, K. Hannah AU - McLean, A. Siân AU - Rodgers, Rachel AU - Fuller-Tyszkiewicz, Matthew AU - Paxton, Susan AU - O'Gorman, Beth AU - Harris, Emily AU - Shatte, Adrian AU - Bishop, Katie AU - Baumann, Tahlia AU - Mahoney, Danielle AU - Daugelat, Melissa-Claire AU - Yager, Zali PY - 2022/10/31 TI - Informing mHealth and Web-Based Eating Disorder Interventions: Combining Lived Experience Perspectives With Design Thinking Approaches JO - JMIR Form Res SP - e38387 VL - 6 IS - 10 KW - eating disorders KW - app-based intervention KW - lived experience KW - design thinking KW - interviews KW - young women KW - co-design KW - mobile health KW - mHealth N2 - Background: App-based interventions designed to prevent and treat eating disorders have considerable potential to overcome known barriers to treatment seeking. Existing apps have shown efficacy in terms of symptom reduction; however, uptake and retention issues are common. To ensure that apps meet the needs and preferences of those for whom they were designed, it is critical to understand the lived experience of potential users and involve them in the process of design, development, and delivery. However, few app-based interventions are pretested on and co-designed with end users before randomized controlled trials. Objective: To address the issue, this study used a highly novel design thinking approach to provide the context and a lived experience perspective of the end user, thus allowing for a deeper level of understanding. Methods: In total, 7 young women (mean age 25.83, SD 5.34, range 21-33 years) who self-identified as having a history of body image issues or eating disorders were recruited. Participants were interviewed about their lived experience of body image and eating disorders and reported their needs and preferences for app-based eating disorder interventions. Traditional (thematic analysis) and novel (empathy mapping; visually depicting and empathizing with the user?s personal experience) analyses were performed, providing a lived experience perspective of eating disorders and identifying the needs and preferences of this population in relation to app-based interventions for eating disorders. Key challenges and opportunities for app-based eating disorder interventions were also identified. Results: Findings highlighted the importance of understanding and identifying problematic eating disorder symptoms for the user, helpful practices for recovery that identify personal values and goals, the role of social support in facilitating hope, and aspects of usability to promote continued engagement and recovery. Conclusions: Practical guidance and recommendations are described for those developing app-based eating disorder interventions. These findings have the potential to inform practices to enhance participant uptake and retention in the context of app-based interventions for this population. UR - https://formative.jmir.org/2022/10/e38387 UR - http://dx.doi.org/10.2196/38387 UR - http://www.ncbi.nlm.nih.gov/pubmed/36315225 ID - info:doi/10.2196/38387 ER - TY - JOUR AU - Tang, W. Wymann S. AU - Ng, Y. Tricia J. AU - Wong, A. Joseph Z. AU - Ho, H. Cyrus S. PY - 2022/8/29 TI - The Role of Serious Video Games in the Treatment of Disordered Eating Behaviors: Systematic Review JO - J Med Internet Res SP - e39527 VL - 24 IS - 8 KW - serious video games KW - serious games KW - video games KW - gamification KW - digital health KW - eHealth KW - mobile health KW - mHealth KW - disordered eating KW - eating disorders N2 - Background: Eating disorders and other forms of disordered eating cause significant complications and comorbidities in patients. However, full remission with current standard treatment remains low. Challenges to treatment include underdiagnosis and high dropout rates, as well as difficulties in addressing underlying emotion dysregulation, poor impulse control, and personality traits. Serious video games (SVGs), which have the advantages of being highly engaging and accessible, may be potential tools for delivering various forms of treatment in addressing the underlying psychopathology of disordered eating. Objective: This review aims to provide an overview of the possible mechanisms by which SVGs may affect the clinical course of disordered eating, while evaluating the outcomes of studies that have assessed the role of SVGs in the treatment of disordered eating. Methods: A systematic search was performed on PubMed, PsycINFO, and Embase, using keywords related to SVGs, disordered eating, and eating disorders. A narrative synthesis was subsequently carried out. Results: In total, 2151 papers were identified, of which 11 (0.51%) were included. Of these 11 studies, 10 (91%) were randomized controlled trials, and 1 (9%) was a quasi-experimental study. The types of SVG interventions varied across the studies and targeted different mechanisms of disordered eating, ranging from addressing problem-solving and emotion regulation skills to neurocognitive training for inhibitory control. Most (10/11, 91%) of the studies showed some benefit of the SVGs in improving certain physical, behavioral, or psychological outcomes related to disordered eating. Some (4/11, 36%) of the studies also showed encouraging evidence of the retention of these benefits at follow-up. Conclusions: The studies included in this review provide collective evidence to suggest the various roles SVGs can play in plugging potential gaps in conventional therapy. Nonetheless, challenges exist in designing these games to prevent potential pitfalls, such as excessive stress arising from the SVGs themselves or potential gaming addiction. Further studies will also be required to assess the long-term benefits of SVGs as well as explore their potential preventive, and not just curative, effects on disordered eating. UR - https://www.jmir.org/2022/8/e39527 UR - http://dx.doi.org/10.2196/39527 UR - http://www.ncbi.nlm.nih.gov/pubmed/36036967 ID - info:doi/10.2196/39527 ER - TY - JOUR AU - Vega, Julio AU - Bell, T. Beth AU - Taylor, Caitlin AU - Xie, Jue AU - Ng, Heidi AU - Honary, Mahsa AU - McNaney, Roisin PY - 2022/4/25 TI - Detecting Mental Health Behaviors Using Mobile Interactions: Exploratory Study Focusing on Binge Eating JO - JMIR Ment Health SP - e32146 VL - 9 IS - 4 KW - eating disorder KW - binge eating KW - mental health KW - mobile sensing KW - context-aware computing KW - NAP KW - EMA KW - mobile phone N2 - Background: Binge eating is a subjective loss of control while eating, which leads to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviors (eg, meal skipping, overexercising, or vomiting). Objective: The aim of this study was to explore the potential of mobile sensing to detect indicators of binge-eating episodes, with a view toward informing the design of future context-aware mobile interventions. Methods: This study was conducted in 2 stages. The first involved the development of the DeMMI (Detecting Mental health behaviors using Mobile Interactions) app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were useful and appropriate, as well as to gather feedback on some specific app features relating to self-reporting. The second stage involved conducting a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted after the study, which discussed their experience using the app, and 8 participants (n=3, 38% binge eating and n=5, 63% comparisons) consented. Results: The findings showed unique differences in the types of sensor data that were triangulated with the individuals? episodes (with nearby Bluetooth devices, screen and app use features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased participants? awareness of and reflection on their mood and phone usage patterns. Moreover, they expressed no privacy concerns as these were alleviated by the study information sheet. Conclusions: This study contributes a series of recommendations for future studies wishing to scale our approach and for the design of bespoke mobile interventions to support this population. UR - https://mental.jmir.org/2022/4/e32146 UR - http://dx.doi.org/10.2196/32146 UR - http://www.ncbi.nlm.nih.gov/pubmed/35086064 ID - info:doi/10.2196/32146 ER - TY - JOUR AU - Chan, W. William AU - Fitzsimmons-Craft, E. Ellen AU - Smith, C. Arielle AU - Firebaugh, Marie-Laure AU - Fowler, A. Lauren AU - DePietro, Bianca AU - Topooco, Naira AU - Wilfley, E. Denise AU - Taylor, Barr C. AU - Jacobson, C. Nicholas PY - 2022/1/19 TI - The Challenges in Designing a Prevention Chatbot for Eating Disorders: Observational Study JO - JMIR Form Res SP - e28003 VL - 6 IS - 1 KW - chatbot KW - eating disorders KW - digital mental health KW - prevention KW - intervention development N2 - Background: Chatbots have the potential to provide cost-effective mental health prevention programs at scale and increase interactivity, ease of use, and accessibility of intervention programs. Objective: The development of chatbot prevention for eating disorders (EDs) is still in its infancy. Our aim is to present examples of and solutions to challenges in designing and refining a rule-based prevention chatbot program for EDs, targeted at adult women at risk for developing an ED. Methods: Participants were 2409 individuals who at least began to use an EDs prevention chatbot in response to social media advertising. Over 6 months, the research team reviewed up to 52,129 comments from these users to identify inappropriate responses that negatively impacted users? experience and technical glitches. Problems identified by reviewers were then presented to the entire research team, who then generated possible solutions and implemented new responses. Results: The most common problem with the chatbot was a general limitation in understanding and responding appropriately to unanticipated user responses. We developed several workarounds to limit these problems while retaining some interactivity. Conclusions: Rule-based chatbots have the potential to reach large populations at low cost but are limited in understanding and responding appropriately to unanticipated user responses. They can be most effective in providing information and simple conversations. Workarounds can reduce conversation errors. UR - https://formative.jmir.org/2022/1/e28003 UR - http://dx.doi.org/10.2196/28003 UR - http://www.ncbi.nlm.nih.gov/pubmed/35044314 ID - info:doi/10.2196/28003 ER - TY - JOUR AU - Feldhege, Johannes AU - Moessner, Markus AU - Bauer, Stephanie PY - 2021/10/6 TI - Detrimental Effects of Online Pro?Eating Disorder Communities on Weight Loss and Desired Weight: Longitudinal Observational Study JO - J Med Internet Res SP - e27153 VL - 23 IS - 10 KW - pro-eating disorder communities KW - weight loss KW - body weight KW - social media KW - linear growth models KW - eating disorders KW - pro-ED KW - Reddit N2 - Background: Online pro?eating disorder (pro-ED) communities are considered harmful because of their detrimental effects on their users? body dissatisfaction, dieting, and help seeking. To date, it is unknown to which extent participation in pro-ED communities affects users? body weight and desired weight loss. Objective: This study aims to investigate the changes in the current and desired body weight of users of a pro-ED community (r/proed) on the social media website Reddit over time. Methods: Data on 1170 users and the unsolicited weight information they shared with the pro-ED community were collected over a period of 15 months. Linear growth models were used to model changes in the users? current and desired BMI over time. Results: Both current and desired BMI decreased over time, with a predicted rate of 0.087 and 0.015 BMI points per week, respectively. Weight loss was moderated by the users? activity level in the community, with more active users losing more weight. Users with a higher baseline BMI experienced greater weight loss, but even users with a very low baseline weight (BMI <17 kg/m2) lost weight during their participation. In addition, users decreased their desired weight over time, with many pursuing extremely low, unrealistic weight goals. Changes in the desired weight were moderated by the baseline current BMI and baseline desired BMI. Users with higher desired weight and lower body weight at baseline decreased their desired weight more over time. Conclusions: This is the first study to demonstrate the detrimental effects of pro-ED communities in a longitudinal study based on a large data set of user-generated online data. The results extend the literature detailing the harmful effects of online pro-ED communities by showing users? weight loss, decreases in desired weight, and that higher activity levels lead to greater weight loss. Users could be driven to pursue very low, unrealistic weight loss goals by images of very thin bodies presented in these communities. UR - https://www.jmir.org/2021/10/e27153 UR - http://dx.doi.org/10.2196/27153 UR - http://www.ncbi.nlm.nih.gov/pubmed/34612830 ID - info:doi/10.2196/27153 ER - TY - JOUR AU - Langlet, Sundström Billy AU - Odegi, Dorothy AU - Zandian, Modjtaba AU - Nolstam, Jenny AU - Södersten, Per AU - Bergh, Cecilia PY - 2021/4/13 TI - Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study JO - JMIR Serious Games SP - e24998 VL - 9 IS - 2 KW - feeding and eating disorders KW - anorexia nervosa KW - bulimia nervosa KW - binge eating disorder KW - immersive virtual reality KW - eating disorders KW - virtual reality N2 - Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall ?good? rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the ?accuracy? item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. UR - https://games.jmir.org/2021/2/e24998 UR - http://dx.doi.org/10.2196/24998 UR - http://www.ncbi.nlm.nih.gov/pubmed/33847593 ID - info:doi/10.2196/24998 ER - TY - JOUR AU - Milton, Clare Alyssa AU - Hambleton, Ashlea AU - Dowling, Mitchell AU - Roberts, Elizabeth Anna AU - Davenport, Tracey AU - Hickie, Ian PY - 2021/2/16 TI - Technology-Enabled Reform in a Nontraditional Mental Health Service for Eating Disorders: Participatory Design Study JO - J Med Internet Res SP - e19532 VL - 23 IS - 2 KW - eating disorders KW - body image KW - mental health KW - technology KW - co-design KW - participatory design KW - service reform KW - consumer engagement N2 - Background: The recent Australian National Agenda for Eating Disorders highlights the role technology can play in improving accessibility and service development through web-based prevention, early access pathways, self-help, and recovery assistance. However, engagement with the eating disorders community to co-design, build, and evaluate these much-needed technology solutions through participatory design processes has been lacking and, until recently, underresourced. Objective: This study aims to customize and configure a technology solution for a nontraditional (web-based, phone, email) mental health service that provides support for eating disorders and body image issues through the use of participatory design processes. Methods: Participants were recruited chiefly through the Butterfly National Helpline 1800 ED HOPE (Butterfly?s National Helpline), an Australian-wide helpline supporting anyone concerned by an eating disorder or body image issue. Participants included individuals with lived experience of eating disorders and body image issues, their supportive others (such as family, health professionals, support workers), and staff of the Butterfly Foundation. Participants took part in participatory design workshops, running up to four hours, which were held nationally in urban and regional locations. The workshop agenda followed an established process of discovery, evaluation, and prototyping. Workshop activities included open and prompted discussion, reviewing working prototypes, creating descriptive artifacts, and developing user journeys. Workshop artifacts were used in a knowledge translation process, which identified key learnings to inform user journeys, user personas, and the customization and configuration of the InnoWell Platform for Butterfly?s National Helpline. Further, key themes were identified using thematic techniques and coded in NVivo 12 software. Results: Six participatory design workshops were held, of which 45 participants took part. Participants highlighted that there is a critical need to address some of the barriers to care, particularly in regional and rural areas. The workshops highlighted seven overarching qualitative themes: identified barriers to care within the current system; need for people to be able to access the right care anywhere, anytime; recommendations for the technological solution (ie, InnoWell Platform features and functionality); need for communication, coordination, and integration of a technological solution embedded in Butterfly?s National Helpline; need to consider engagement and tone within the technological solution; identified challenges and areas to consider when implementing a technological solution in the Helpline; and potential outcomes of the technological solution embedded in the Helpline relating to system and service reform. Ultimately, this technology solution should ensure that the right care is provided to individuals the first time. Conclusions: Our findings highlight the value of actively engaging stakeholders in participatory design processes for the customization and configuration of new technologies. End users can highlight the critical areas of need, which can be used as a catalyst for reform through the implementation of these technologies in nontraditional services. UR - http://www.jmir.org/2021/2/e19532/ UR - http://dx.doi.org/10.2196/19532 UR - http://www.ncbi.nlm.nih.gov/pubmed/33591283 ID - info:doi/10.2196/19532 ER - TY - JOUR AU - Humphreys, Gabrielle AU - Evans, Rebecca AU - Makin, Harriet AU - Cooke, Richard AU - Jones, Andrew PY - 2021/2/9 TI - Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review JO - J Med Internet Res SP - e22694 VL - 23 IS - 2 KW - systematic review KW - web-based intervention KW - behavior and behavior mechanism KW - behavior change technique KW - alcohol consumption KW - binge eating KW - gambling N2 - Background: Web-based interventions are thought to overcome barriers to treatment, such as accessibility and geographical location, which can undermine the effectiveness of traditional face-to-face interventions. Owing to these features, researchers are increasingly testing the efficacy of web-based interventions as ways to reduce alcohol misuse, binge eating, and gambling. However, many web-based interventions have poorly defined mechanisms of action; therefore, it is often uncertain how they propose to bring about behavior change. Objective: This systematic review aims to identify effective behavior change techniques (BCTs) present in web-based interventions aimed at reducing alcohol consumption, binge eating, or gambling. Methods: This systematic review covered research conducted in the last 20 years. Inclusion criteria for interventions were web-based administration; targeting alcohol use, binge eating, and/or gambling; and reporting on baseline and postintervention measures of behavior. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. We coded intervention effectiveness, study quality, and BCTs present in the interventions. Results: Following removal of 4152 ineligible articles, 45 were included in the review: 32 (71%) targeted alcohol misuse, 6 (13%) targeted binge eating, and 7 (16%) targeted gambling. In total, 5 frequency counts were performed to identify the most commonly used BCTs: all studies, effective interventions, high-quality studies at 2 thresholds, and both high quality and effective studies. The results obtained from this were integrated to identify 7 BCTs. These 7 BCTs were problem solving, feedback on behavior, self-monitoring of behavior, self-monitoring of outcomes, instruction on how to perform a behavior, information about social and health consequences, and social comparison. A total of 4 BCTs were found in all frequency counts: feedback on behavior, self-monitoring of behavior, instruction on how to perform a behavior, and social comparison. Self-monitoring of outcomes of behavior was found in 3 of the 5 frequency counts, problem solving was found in 2 frequency counts, and information about social and health consequences was found in 1 frequency count. Conclusions: This systematic review identified 7 of the most frequently used BCTs used in web-based interventions focused on alcohol misuse, binge eating, and gambling. These results can inform the development of evidence-based eHealth interventions that have the potential to lead to effective, positive behavior changes in all 3 areas. UR - http://www.jmir.org/2021/2/e22694/ UR - http://dx.doi.org/10.2196/22694 UR - http://www.ncbi.nlm.nih.gov/pubmed/33560243 ID - info:doi/10.2196/22694 ER - TY - JOUR AU - Viguria, Iranzu AU - Alvarez-Mon, Angel Miguel AU - Llavero-Valero, Maria AU - Asunsolo del Barco, Angel AU - Ortuño, Felipe AU - Alvarez-Mon, Melchor PY - 2020/7/14 TI - Eating Disorder Awareness Campaigns: Thematic and Quantitative Analysis Using Twitter JO - J Med Internet Res SP - e17626 VL - 22 IS - 7 KW - awareness campaigns KW - eating disorders KW - Twitter KW - social media N2 - Background: Health awareness initiatives are frequent but their efficacy is a matter of controversy. We have investigated the effect of the Eating Disorder Awareness Week and Wake Up Weight Watchers campaigns on Twitter. Objective: We aimed to examine whether the Eating Disorder Awareness Week and Wake Up Weight Watchers initiatives increased the volume and dissemination of Twitter conversations related to eating disorders and investigate what content generates the most interest on Twitter. Methods: Over a period of 12 consecutive days in 2018, we collected tweets containing the hashtag #wakeupweightwatchers and hashtags related to Eating Disorder Awareness Week (#eatingdisorderawarenessweek, #eatingdisorderawareness, or #EDAW), with the hashtag #eatingdisorder as a control. The content of each tweet was rated as medical, testimony, help offer, awareness, pro-ana, or anti-ana. We analyzed the number of retweets and favorites generated, as well as the potential reach and impact of the hashtags and the characteristics of contributors. Results: The number of #wakeupweightwatchers tweets was higher than that of Eating Disorder Awareness Week and #eatingdisorder tweets (3900, 2056, and 1057, respectively). The content of tweets was significantly different between the hashtags analyzed (P<.001). Medical content was lower in the awareness campaigns. Awareness and help offer content were lower in #wakeupweightwatchers tweets. Retweet and favorite ratios were highest in #wakeupweightwatchers tweets. Eating Disorder Awareness Week achieved the highest impact, and very influential contributors participated. Conclusions: Both awareness campaigns effectively promoted tweeting about eating disorders. The majority of tweets did not promote any specific preventive or help-seeking behaviors. UR - http://www.jmir.org/2020/7/e17626/ UR - http://dx.doi.org/10.2196/17626 UR - http://www.ncbi.nlm.nih.gov/pubmed/32673225 ID - info:doi/10.2196/17626 ER - TY - JOUR AU - Brown, Theresa AU - Nauman Vogel, Emily AU - Adler, Sarah AU - Bohon, Cara AU - Bullock, Kim AU - Nameth, Katherine AU - Riva, Giuseppe AU - Safer, L. Debra AU - Runfola, D. Cristin PY - 2020/4/23 TI - Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy JO - J Med Internet Res SP - e16386 VL - 22 IS - 4 KW - virtual reality KW - exposure therapy KW - eating disorders KW - translational research KW - technological innovation UR - http://www.jmir.org/2020/4/e16386/ UR - http://dx.doi.org/10.2196/16386 UR - http://www.ncbi.nlm.nih.gov/pubmed/32324145 ID - info:doi/10.2196/16386 ER - TY - JOUR AU - Funk, Burkhardt AU - Sadeh-Sharvit, Shiri AU - Fitzsimmons-Craft, E. Ellen AU - Trockel, Todd Mickey AU - Monterubio, E. Grace AU - Goel, J. Neha AU - Balantekin, N. Katherine AU - Eichen, M. Dawn AU - Flatt, E. Rachael AU - Firebaugh, Marie-Laure AU - Jacobi, Corinna AU - Graham, K. Andrea AU - Hoogendoorn, Mark AU - Wilfley, E. Denise AU - Taylor, Barr C. PY - 2020/2/19 TI - A Framework for Applying Natural Language Processing in Digital Health Interventions JO - J Med Internet Res SP - e13855 VL - 22 IS - 2 KW - Digital Health Interventions Text Analytics (DHITA) KW - digital health interventions KW - eating disorders KW - guided self-help KW - natural language processing KW - text mining N2 - Background: Digital health interventions (DHIs) are poised to reduce target symptoms in a scalable, affordable, and empirically supported way. DHIs that involve coaching or clinical support often collect text data from 2 sources: (1) open correspondence between users and the trained practitioners supporting them through a messaging system and (2) text data recorded during the intervention by users, such as diary entries. Natural language processing (NLP) offers methods for analyzing text, augmenting the understanding of intervention effects, and informing therapeutic decision making. Objective: This study aimed to present a technical framework that supports the automated analysis of both types of text data often present in DHIs. This framework generates text features and helps to build statistical models to predict target variables, including user engagement, symptom change, and therapeutic outcomes. Methods: We first discussed various NLP techniques and demonstrated how they are implemented in the presented framework. We then applied the framework in a case study of the Healthy Body Image Program, a Web-based intervention trial for eating disorders (EDs). A total of 372 participants who screened positive for an ED received a DHI aimed at reducing ED psychopathology (including binge eating and purging behaviors) and improving body image. These users generated 37,228 intervention text snippets and exchanged 4285 user-coach messages, which were analyzed using the proposed model. Results: We applied the framework to predict binge eating behavior, resulting in an area under the curve between 0.57 (when applied to new users) and 0.72 (when applied to new symptom reports of known users). In addition, initial evidence indicated that specific text features predicted the therapeutic outcome of reducing ED symptoms. Conclusions: The case study demonstrates the usefulness of a structured approach to text data analytics. NLP techniques improve the prediction of symptom changes in DHIs. We present a technical framework that can be easily applied in other clinical trials and clinical presentations and encourage other groups to apply the framework in similar contexts. UR - https://www.jmir.org/2020/2/e13855 UR - http://dx.doi.org/10.2196/13855 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130118 ID - info:doi/10.2196/13855 ER - TY - JOUR AU - Aupperle, Leora Robin AU - Paulus, P. Martin AU - Kuplicki, Rayus AU - Touthang, James AU - Victor, Teresa AU - Yeh, Hung-Wen AU - AU - Khalsa, S. Sahib PY - 2020/1/28 TI - Web-Based Graphic Representation of the Life Course of Mental Health: Cross-Sectional Study Across the Spectrum of Mood, Anxiety, Eating, and Substance Use Disorders JO - JMIR Ment Health SP - e16919 VL - 7 IS - 1 KW - mental health KW - life history KW - psychosocial factors KW - depression KW - anxiety KW - substance use disorders KW - eating disorders N2 - Background: Although patient history is essential for informing mental health assessment, diagnosis, and prognosis, there is a dearth of standardized instruments measuring time-dependent factors relevant to psychiatric disorders. Previous research has demonstrated the potential utility of graphical representations, termed life charts, for depicting the complexity of the course of mental illness. However, the implementation of these assessments is limited by the exclusive focus on specific mental illnesses (ie, bipolar disorder) and the lack of intuitive graphical interfaces for data collection and visualization. Objective: This study aimed to develop and test the utility of the Tulsa Life Chart (TLC) as a Web-based, structured approach for obtaining and graphically representing historical information on psychosocial and mental health events relevant across a spectrum of psychiatric disorders. Methods: The TLC interview was completed at baseline by 499 participants of the Tulsa 1000, a longitudinal study of individuals with depressive, anxiety, substance use, or eating disorders and healthy comparisons (HCs). All data were entered electronically, and a 1-page electronic and interactive graphical representation was developed using the Google Visualization Application Programming Interface. For 8 distinct life epochs (periods of approximately 5-10 years), the TLC assessed the following factors: school attendance, hobbies, jobs, social support, substance use, mental health treatment, family structure changes, negative and positive events, and epoch and event-related mood ratings. We used generalized linear mixed models (GLMMs) to evaluate trajectories of each domain over time and by sex, age, and diagnosis, using case examples and Web-based interactive graphs to visualize data. Results: GLMM analyses revealed main or interaction effects of epoch and diagnosis for all domains. Epoch by diagnosis interactions were identified for mood ratings and the number of negative-versus-positive events (all P values <.001), with all psychiatric groups reporting worse mood and greater negative-versus-positive events than HCs. These differences were most robust at different epochs, depending on diagnosis. There were also diagnosis and epoch main effects for substance use, mental health treatment received, social support, and hobbies (P<.001). User experience ratings (each on a 1-5 scale) revealed that participants found the TLC pleasant to complete (mean 3.07, SD 1.26) and useful for understanding their mental health (mean 3.07, SD 1.26), and that they were likely to recommend it to others (mean 3.42, SD 0.85). Conclusions: The TLC provides a structured, Web-based transdiagnostic assessment of psychosocial history relevant for the diagnosis and treatment of psychiatric disorders. Interactive, 1-page graphical representations of the TLC allow for the efficient communication of historical life information that would be useful for clinicians, patients, and family members. UR - http://mental.jmir.org/2020/1/e16919/ UR - http://dx.doi.org/10.2196/16919 UR - http://www.ncbi.nlm.nih.gov/pubmed/32012081 ID - info:doi/10.2196/16919 ER - TY - JOUR AU - Goodday, M. Sarah AU - Atkinson, Lauren AU - Goodwin, Guy AU - Saunders, Kate AU - South, Matthew AU - Mackay, Clare AU - Denis, Mike AU - Hinds, Chris AU - Attenburrow, Mary-Jane AU - Davies, Jim AU - Welch, James AU - Stevens, William AU - Mansfield, Karen AU - Suvilehto, Juulia AU - Geddes, John PY - 2020/1/15 TI - The True Colours Remote Symptom Monitoring System: A Decade of Evolution JO - J Med Internet Res SP - e15188 VL - 22 IS - 1 KW - symptom assessment KW - signs and symptoms KW - digital health KW - ecological momentary assessment KW - mood disorders UR - https://www.jmir.org/2020/1/e15188 UR - http://dx.doi.org/10.2196/15188 UR - http://www.ncbi.nlm.nih.gov/pubmed/31939746 ID - info:doi/10.2196/15188 ER - TY - JOUR AU - Wahl, Ronja Deborah AU - Villinger, Karoline AU - Blumenschein, Michael AU - König, Maria Laura AU - Ziesemer, Katrin AU - Sproesser, Gudrun AU - Schupp, Thomas Harald AU - Renner, Britta PY - 2020/1/7 TI - Why We Eat What We Eat: Assessing Dispositional and In-the-Moment Eating Motives by Using Ecological Momentary Assessment JO - JMIR Mhealth Uhealth SP - e13191 VL - 8 IS - 1 KW - mHealth KW - eating KW - motivation KW - mobile app KW - EMA KW - in-the-moment KW - disposition KW - trait KW - state N2 - Background: Why do we eat? Our motives for eating are diverse, ranging from hunger and liking to social norms and affect regulation. Although eating motives can vary from eating event to eating event, which implies substantial moment-to-moment differences, current ways of measuring eating motives rely on single timepoint questionnaires that assess eating motives as situation-stable dispositions (traits). However, mobile technologies including smartphones allow eating events and motives to be captured in real time and real life, thus capturing experienced eating motives in-the-moment (states). Objective: This study aimed to examine differences between why people think they eat (trait motives) and why they eat in the moment of consumption (state motives) by comparing a dispositional (trait) and an in-the-moment (state) assessment of eating motives. Methods: A total of 15 basic eating motives included in The Eating Motivation Survey (ie, liking, habit, need and hunger, health, convenience, pleasure, traditional eating, natural concerns, sociability, price, visual appeal, weight control, affect regulation, social norms, and social image) were assessed in 35 participants using 2 methodological approaches: (1) a single timepoint dispositional assessment and (2) a smartphone-based ecological momentary assessment (EMA) across 8 days (N=888 meals) capturing eating motives in the moment of eating. Similarities between dispositional and in-the-moment eating motive profiles were assessed according to 4 different indices of profile similarity, that is, overall fit, shape, scatter, and elevation. Moreover, a visualized person × motive data matrix was created to visualize and analyze between- and within-person differences in trait and state eating motives. Results: Similarity analyses yielded a good overall fit between the trait and state eating motive profiles across participants, indicated by a double-entry intraclass correlation of 0.52 (P<.001). However, although trait and state motives revealed a comparable rank order (r=0.65; P<.001), trait motives overestimated 12 of 15 state motives (P<.001; d=1.97). Specifically, the participants assumed that 6 motives (need and hunger, price, habit, sociability, traditional eating, and natural concerns) are more essential for eating than they actually were in the moment (d>0.8). Furthermore, the visualized person × motive data matrix revealed substantial interindividual differences in intraindividual motive profiles. Conclusions: For a comprehensive understanding of why we eat what we eat, dispositional assessments need to be extended by in-the-moment assessments of eating motives. Smartphone-based EMAs reveal considerable intra- and interindividual differences in eating motives, which are not captured by single timepoint dispositional assessments. Targeting these differences between why people think they eat what they eat and why they actually eat in the moment may hold great promise for tailored mobile health interventions facilitating behavior changes. UR - https://mhealth.jmir.org/2020/1/e13191 UR - http://dx.doi.org/10.2196/13191 UR - http://www.ncbi.nlm.nih.gov/pubmed/31909719 ID - info:doi/10.2196/13191 ER - TY - JOUR AU - Tregarthen, Jenna AU - Paik Kim, Jane AU - Sadeh-Sharvit, Shiri AU - Neri, Eric AU - Welch, Hannah AU - Lock, James PY - 2019/11/21 TI - Comparing a Tailored Self-Help Mobile App With a Standard Self-Monitoring App for the Treatment of Eating Disorder Symptoms: Randomized Controlled Trial JO - JMIR Ment Health SP - e14972 VL - 6 IS - 11 KW - mobile health KW - smartphone KW - mobile apps KW - eating disorders KW - cognitive behavioral therapy KW - mental health KW - intervention study N2 - Background: Eating disorders severely impact psychological, physical, and social functioning, and yet, the majority of individuals with eating disorders do not receive treatment. Mobile health apps have the potential to decrease access barriers to care and reach individuals who have been underserved by traditional treatment modalities. Objective: The objective of this study was to evaluate the effectiveness of a tailored, fully automated self-help version of Recovery Record, an app developed for eating disorders management. We examined differences in eating disorder symptom change in app users that were randomized to receive either a standard, cognitive behavioral therapy?based version of the app or a tailored version that included algorithmically determined clinical content aligned with baseline and evolving user eating disorder symptom profiles. Methods: Participants were people with eating disorder symptoms who did not have access to traditional treatment options and were recruited via the open-access Recovery Record app to participate in this randomized controlled trial. We examined both continuous and categorical clinical improvement outcomes (measured with the self-report Eating Disorder Examination Questionnaire [EDE-Q]) in both intervention groups. Results: Between December 2016 and August 2018, 3294 Recovery Record app users were recruited into the study, out of which 959 were considered engaged, completed follow-up assessments, and were included in the analyses. Both study groups achieved significant overall outcome improvement, with 61.6% (180/292) of the tailored group and 55.4% (158/285) of the standard group achieving a clinically meaningful change in the EDE-Q, on average. There were no statistically significant differences between randomized groups for continuous outcomes, but a pattern of improvement being greater in the tailored group was evident. The rate of remission on the EDE-Q at 8 weeks was significantly greater in the group receiving the tailored version (d=0.22; P?.001). Conclusions: This is the first report to compare the relative efficacy of two versions of a mobile app for eating disorders. The data suggest that underserved individuals with eating disorder symptoms may benefit clinically from a self-help app and that personalizing app content to specific clinical presentations may be more effective in promoting symptomatic remission on the EDE-Q than content that offers a generic approach. Trial Registration: ClinicalTrials.gov NCT02503098; https://clinicaltrials.gov/ct2/show/NCT02503098. UR - http://mental.jmir.org/2019/11/e14972/ UR - http://dx.doi.org/10.2196/14972 UR - http://www.ncbi.nlm.nih.gov/pubmed/31750837 ID - info:doi/10.2196/14972 ER - TY - JOUR AU - Ralph-Nearman, Christina AU - Arevian, C. Armen AU - Puhl, Maria AU - Kumar, Rajay AU - Villaroman, Diane AU - Suthana, Nanthia AU - Feusner, D. Jamie AU - Khalsa, S. Sahib PY - 2019/10/29 TI - A Novel Mobile Tool (Somatomap) to Assess Body Image Perception Pilot Tested With Fashion Models and Nonmodels: Cross-Sectional Study JO - JMIR Ment Health SP - e14115 VL - 6 IS - 10 KW - body image KW - body perception KW - body representation KW - body image disorder KW - eating disorder KW - mobile health KW - mental health KW - mobile app KW - digital health N2 - Background: Distorted perception of one?s body and appearance, in general, is a core feature of several psychiatric disorders including anorexia nervosa and body dysmorphic disorder and is operative to varying degrees in nonclinical populations. Yet, body image perception is challenging to assess, given its subjective nature and variety of manifestations. The currently available methods have several limitations including restricted ability to assess perceptions of specific body areas. To address these limitations, we created Somatomap, a mobile tool that enables individuals to visually represent their perception of body-part sizes and shapes as well as areas of body concerns and record the emotional valence of concerns. Objective: This study aimed to develop and pilot test the feasibility of a novel mobile tool for assessing 2D and 3D body image perception. Methods: We developed a mobile 2D tool consisting of a manikin figure on which participants outline areas of body concern and indicate the nature, intensity, and emotional valence of the concern. We also developed a mobile 3D tool consisting of an avatar on which participants select individual body parts and use sliders to manipulate their size and shape. The tool was pilot tested on 103 women: 65 professional fashion models, a group disproportionately exposed to their own visual appearance, and 38 nonmodels from the general population. Acceptability was assessed via a usability rating scale. To identify areas of body concern in 2D, topographical body maps were created by combining assessments across individuals. Statistical body maps of group differences in body concern were subsequently calculated using the formula for proportional z-score. To identify areas of body concern in 3D, participants? subjective estimates from the 3D avatar were compared to corresponding measurements of their actual body parts. Discrepancy scores were calculated based on the difference between the perceived and actual body parts and evaluated using multivariate analysis of covariance. Results: Statistical body maps revealed different areas of body concern between models (more frequently about thighs and buttocks) and nonmodels (more frequently about abdomen/waist). Models were more accurate at estimating their overall body size, whereas nonmodels tended to underestimate the size of individual body parts, showing greater discrepancy scores for bust, biceps, waist, hips, and calves but not shoulders and thighs. Models and nonmodels reported high ease-of-use scores (8.4/10 and 8.5/10, respectively), and the resulting 3D avatar closely resembled their actual body (72.7% and 75.2%, respectively). Conclusions: These pilot results suggest that Somatomap is feasible to use and offers new opportunities for assessment of body image perception in mobile settings. Although further testing is needed to determine the applicability of this approach to other populations, Somatomap provides unique insight into how humans perceive and represent the visual characteristics of their body. UR - http://mental.jmir.org/2019/10/e14115/ UR - http://dx.doi.org/10.2196/14115 UR - http://www.ncbi.nlm.nih.gov/pubmed/31469647 ID - info:doi/10.2196/14115 ER - TY - JOUR AU - Hamatani, Sayo AU - Numata, Noriko AU - Matsumoto, Kazuki AU - Sutoh, Chihiro AU - Ibuki, Hanae AU - Oshiro, Keiko AU - Tanaka, Mari AU - Setsu, Rikukage AU - Kawasaki, Yohei AU - Hirano, Yoshiyuki AU - Shimizu, Eiji PY - 2019/10/23 TI - Internet-Based Cognitive Behavioral Therapy via Videoconference for Patients With Bulimia Nervosa and Binge-Eating Disorder: Pilot Prospective Single-Arm Feasibility Trial JO - JMIR Form Res SP - e15738 VL - 3 IS - 4 KW - bulimia nervosa KW - binge-eating disorder KW - cognitive behavioral therapy KW - internet-based cognitive behavioral therapy KW - videoconference N2 - Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa and binge-eating disorder in Japan. Objective: The goal of the research was to evaluate the feasibility of ICBT via videoconference for patients with bulimia nervosa or binge-eating disorder. Methods: Seven Japanese subjects (mean age 31.9 [SD 7.9] years) with bulimia nervosa and binge-eating disorder received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination Edition 16.0D (EDE 16D) for bulimia nervosa and binge-eating disorder: the combined objective binge and purging episodes, objective binge episodes, and purging episodes. The secondary outcomes were the Eating Disorders Examination Questionnaire, Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, Motivational Ruler for motivation to change, EuroQol-5 Dimension for quality of life, 9-item Patient Health Questionnaire for depression, 7-item Generalized Anxiety Disorder scale for anxiety, and Working Alliance Inventory?Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and weeks 8 (midintervention) and 16 (postintervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and 95% confidence intervals using the paired t test. Results: Although the mean combined objective binge and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen d=?0.76), there was no significant reduction in the combined episodes (EDE 16D ?41; 95% CI ?2.089 to 0.576; P=.17). There were no significant treatment-related changes in secondary outcomes. The WAI-SF scores remained consistently high (64.8 to 66.0) during treatment. Conclusions: ICBT via videoconference is feasible in Japanese patients with bulimia nervosa and binge-eating disorder. Trial Registration: UMIN Clinical Trials Registry UMIN000029426; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033419 UR - http://formative.jmir.org/2019/4/e15738/ UR - http://dx.doi.org/10.2196/15738 UR - http://www.ncbi.nlm.nih.gov/pubmed/31647472 ID - info:doi/10.2196/15738 ER - TY - JOUR AU - Anastasiadou, Dimitra AU - Folkvord, Frans AU - Serrano-Troncoso, Eduardo AU - Lupiañez-Villanueva, Francisco PY - 2019/5/31 TI - Mobile Health Adoption in Mental Health: User Experience of a Mobile Health App for Patients With an Eating Disorder JO - JMIR Mhealth Uhealth SP - e12920 VL - 7 IS - 6 KW - eating disorders KW - mental health KW - mHealth KW - mobile applications KW - focus groups N2 - Background: Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low. Objective: This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists. Methods: To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web. Results: The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment (ie, lack of time because of workload, lack of direct interest on a legislative or political level) rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol. Conclusions: In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice. UR - https://mhealth.jmir.org/2019/6/e12920/ UR - http://dx.doi.org/10.2196/12920 UR - http://www.ncbi.nlm.nih.gov/pubmed/31199329 ID - info:doi/10.2196/12920 ER - TY - JOUR AU - Wang, Tao AU - Mentzakis, Emmanouil AU - Brede, Markus AU - Ianni, Antonella PY - 2019/05/03 TI - Estimating Determinants of Attrition in Eating Disorder Communities on Twitter: An Instrumental Variables Approach JO - J Med Internet Res SP - e10942 VL - 21 IS - 5 KW - medical informatics KW - eating disorders KW - social media KW - attrition KW - emotions KW - social network KW - causality KW - instrumental variables N2 - Background: The use of social media as a key health information source has increased steadily among people affected by eating disorders (EDs). Research has examined characteristics of individuals engaging in online communities, whereas little is known about discontinuation of engagement and the phenomenon of participants dropping out of these communities. Objective: This study aimed to investigate the characteristics of dropout behaviors among eating disordered individuals on Twitter and to estimate the causal effects of personal emotions and social networks on dropout behaviors. Methods: Using a snowball sampling method, we collected a set of individuals who self-identified with EDs in their Twitter profile descriptions, as well as their tweets and social networks, leading to 241,243,043 tweets from 208,063 users. Individuals? emotions are measured from their language use in tweets using an automatic sentiment analysis tool, and network centralities are measured from users? following networks. Dropout statuses of users are observed in a follow-up period 1.5 years later (from February 11, 2016 to August 17, 2017). Linear and survival regression instrumental variables models are used to estimate the effects of emotions and network centrality on dropout behaviors. The average levels of attributes among an individual?s followees (ie, people who are followed by the individual) are used as instruments for the individual?s attributes. Results: Eating disordered users have relatively short periods of activity on Twitter with one half of our sample dropping out at 6 months after account creation. Active users show more negative emotions and higher network centralities than dropped-out users. Active users tend to connect to other active users, whereas dropped-out users tend to cluster together. Estimation results suggest that users? emotions and network centralities have causal effects on their dropout behaviors on Twitter. More specifically, users with positive emotions are more likely to drop out and have shorter lasting periods of activity online than users with negative emotions, whereas central users in a social network have longer lasting participation than peripheral users. Findings on users? tweeting interests further show that users who attempt to recover from EDs are more likely to drop out than those who promote EDs as a lifestyle choice. Conclusions: Presence in online communities is strongly determined by the individual?s emotions and social networks, suggesting that studies analyzing and trying to draw condition and population characteristics through online health communities are likely to be biased. Future research needs to examine in more detail the links between individual characteristics and participation patterns if better understanding of the entire population is to be achieved. At the same time, such attrition dynamics need to be acknowledged and controlled when designing online interventions so as to accurately capture their intended populations. UR - https://www.jmir.org/2019/5/e10942/ UR - http://dx.doi.org/10.2196/10942 UR - http://www.ncbi.nlm.nih.gov/pubmed/31066718 ID - info:doi/10.2196/10942 ER - TY - JOUR AU - McCaig, Duncan AU - Elliott, T. Mark AU - Siew, SQ Cynthia AU - Walasek, Lukasz AU - Meyer, Caroline PY - 2019/04/22 TI - Profiling Commenters on Mental Health?Related Online Forums: A Methodological Example Focusing on Eating Disorder?Related Commenters JO - JMIR Ment Health SP - e12555 VL - 6 IS - 4 KW - mental health KW - eating disorders KW - social media KW - social networks N2 - Background: Understanding the characteristics of commenters on mental health?related online forums is vital for the development of effective psychological interventions in these communities. The way in which commenters interact can enhance our understanding of their characteristics. Objective: Using eating disorder?related (EDR) forums as an example, this study detailed a methodology that aimed to determine subtypes of mental health?related forums and profile their commenters based on the other forums to which they contributed. Methods: The researchers identified all public EDR forums (with ?500 contributing commenters between March 2017 and February 2018) on a large Web-based discussion platform (Reddit). A mixed-methods approach comprising network analysis with community detection, text mining, and manual review identified subtypes of EDR forums. For each subtype, another network analysis with community detection was conducted using the EDR forum commenter overlap between 50 forums on which the commenters also commented. The topics of forums in each detected community were then manually reviewed to identify the shared interests of each subtype of EDR forum commenters. Results: Six subtypes of EDR forums were identified, to which 14,024 commenters had contributed. The results focus on 2 subtypes?proeating disorder and thinspiration?and communities of commenters within both subtypes. Within the proeating disorder subtype, 3 communities of commenters were detected that related to the body and eating, mental health, and women, appearance, and mixed topics. With regard to the thinspiration group, 78.17% (849/1086) of commenters had also commented on pornographic forums and 16.66% (181/1086) had contributed to proeating disorder forums. Conclusions: The article exemplifies a methodology that provides insight into subtypes of mental health?related forums and the characteristics of their commenters. The findings have implications for future research and Web-based psychological interventions. With the publicly available data and code provided, researchers can easily reproduce the analyses or utilize the methodology to investigate other mental health?related forums. UR - http://mental.jmir.org/2019/4/e12555/ UR - http://dx.doi.org/10.2196/12555 UR - http://www.ncbi.nlm.nih.gov/pubmed/31008715 ID - info:doi/10.2196/12555 ER - TY - JOUR AU - Jacobi, Corinna AU - Hütter, Kristian AU - Völker, Ulrike AU - Möbius, Katharina AU - Richter, Robert AU - Trockel, Mickey AU - Jones Bell, Megan AU - Lock, James AU - Taylor, Barr C. PY - 2018/12/14 TI - Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial JO - J Med Internet Res SP - e296 VL - 20 IS - 12 KW - anorexia nervosa KW - indicated prevention KW - internet KW - parental intervention KW - randomized controlled trial N2 - Background: Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak. Objective: The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN. Methods: Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU). Results: A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the E@T or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls? expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=?15.5 [CI ?26.6 to ?4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating. Conclusions: Despite a significant increase in girls? EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; http://www.isrctn.com/ISRCTN18614564 (Archived by WebCite at http://www.webcitation.org/74FTV1EpF). UR - http://www.jmir.org/2018/12/e296/ UR - http://dx.doi.org/10.2196/jmir.9464 UR - http://www.ncbi.nlm.nih.gov/pubmed/30552078 ID - info:doi/10.2196/jmir.9464 ER - TY - JOUR AU - van den Boer, Janet AU - van der Lee, Annemiek AU - Zhou, Lingchuan AU - Papapanagiotou, Vasileios AU - Diou, Christos AU - Delopoulos, Anastasios AU - Mars, Monica PY - 2018/09/04 TI - The SPLENDID Eating Detection Sensor: Development and Feasibility Study JO - JMIR Mhealth Uhealth SP - e170 VL - 6 IS - 9 KW - chewing sensor KW - weight management KW - obesity prevention KW - overweight KW - PPG sensor KW - in-ear microphone KW - mobile phone N2 - Background: The available methods for monitoring food intake?which for a great part rely on self-report?often provide biased and incomplete data. Currently, no good technological solutions are available. Hence, the SPLENDID eating detection sensor (an ear-worn device with an air microphone and a photoplethysmogram [PPG] sensor) was developed to enable complete and objective measurements of eating events. The technical performance of this device has been described before. To date, literature is lacking a description of how such a device is perceived and experienced by potential users. Objective: The objective of our study was to explore how potential users perceive and experience the SPLENDID eating detection sensor. Methods: Potential users evaluated the eating detection sensor at different stages of its development: (1) At the start, 12 health professionals (eg, dieticians, personal trainers) were interviewed and a focus group was held with 5 potential end users to find out their thoughts on the concept of the eating detection sensor. (2) Then, preliminary prototypes of the eating detection sensor were tested in a laboratory setting where 23 young adults reported their experiences. (3) Next, the first wearable version of the eating detection sensor was tested in a semicontrolled study where 22 young, overweight adults used the sensor on 2 separate days (from lunch till dinner) and reported their experiences. (4) The final version of the sensor was tested in a 4-week feasibility study by 20 young, overweight adults who reported their experiences. Results: Throughout all the development stages, most individuals were enthusiastic about the eating detection sensor. However, it was stressed multiple times that it was critical that the device be discreet and comfortable to wear for a longer period. In the final study, the eating detection sensor received an average grade of 3.7 for wearer comfort on a scale of 1 to 10. Moreover, experienced discomfort was the main reason for wearing the eating detection sensor <2 hours a day. The participants reported having used the eating detection sensor on 19/28 instructed days on average. Conclusions: The SPLENDID eating detection sensor, which uses an air microphone and a PPG sensor, is a promising new device that can facilitate the collection of reliable food intake data, as shown by its technical potential. Potential users are enthusiastic, but to be successful wearer comfort and discreetness of the device need to be improved. UR - http://mhealth.jmir.org/2018/9/e170/ UR - http://dx.doi.org/10.2196/mhealth.9781 UR - http://www.ncbi.nlm.nih.gov/pubmed/30181111 ID - info:doi/10.2196/mhealth.9781 ER - TY - JOUR AU - Clus, Damien AU - Larsen, Erik Mark AU - Lemey, Christophe AU - Berrouiguet, Sofian PY - 2018/04/27 TI - The Use of Virtual Reality in Patients with Eating Disorders: Systematic Review JO - J Med Internet Res SP - e157 VL - 20 IS - 4 KW - virtual reality exposure therapy KW - feeding and eating disorders KW - binge-eating disorder KW - anorexia nervosa KW - bulimia nervosa N2 - Background: Patients with eating disorders are characterized by pathological eating habits and a tendency to overestimate their weight and body shape. Virtual reality shows promise for the evaluation and management of patients with eating disorders. This technology, when accepted by this population, allows immersion in virtual environments, assessment, and therapeutic approaches, by exposing users to high-calorie foods or changes in body shape. Objective: To better understand the value of virtual reality, we conducted a review of the literature, including clinical studies proposing the use of virtual reality for the evaluation and management of patients with eating disorders. Methods: We searched PubMed, PsycINFO, ScienceDirect, the Cochrane Library, Scopus, and Web of Science up to April 2017. We created the list of keywords based on two domains: virtual reality and eating disorders. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify, select, and critically appraise relevant research while minimizing bias. Results: The initial database searches identified 311 articles, 149 of which we removed as duplicates. We analyzed the resulting set of 26 unique studies that met the inclusion criteria. Of these, 8 studies were randomized controlled trials, 13 were nonrandomized studies, and 5 were clinical trials with only 1 participant. Most articles focused on clinical populations (19/26, 73%), with the remainder reporting case-control studies (7/26, 27%). Most of the studies used visual immersive equipment (16/26, 62%) with a head-mounted display (15/16, 94%). Two main areas of interest emerged from these studies: virtual work on patients? body image (7/26, 27%) and exposure to virtual food stimuli (10/26, 38%). Conclusions: We conducted a broad analysis of studies on the use of virtual reality in patients with eating disorders. This review of the literature showed that virtual reality is an acceptable and promising therapeutic tool for patients with eating disorders. UR - http://www.jmir.org/2018/4/e157/ UR - http://dx.doi.org/10.2196/jmir.7898 UR - http://www.ncbi.nlm.nih.gov/pubmed/29703715 ID - info:doi/10.2196/jmir.7898 ER - TY - JOUR AU - Yom-Tov, Elad AU - Brunstein-Klomek, Anat AU - Mandel, Or AU - Hadas, Arie AU - Fennig, Silvana PY - 2018/02/22 TI - Inducing Behavioral Change in Seekers of Pro-Anorexia Content Using Internet Advertisements: Randomized Controlled Trial JO - JMIR Ment Health SP - e6 VL - 5 IS - 1 KW - anorexia nervosa KW - bulimia nervosa KW - eating disorders KW - online advertising KW - online behavior KW - Pro-ana N2 - Background: The influence of pro-anorexia (pro-ana) websites is debated, with studies indicating both negative and positive effects, as well as significant variation in the effects of different websites for those suffering from eating disorders (EDs) and the general population. Online advertising, known to induce behavioral change both online and in the physical world, has not been used so far to modify the search behavior of people seeking pro-ana content. Objective: The objective of this randomized controlled trial (RCT) was to examine if online advertisements (ads) can change online search behaviors of users who are looking for online pro-ana content. Methods: Using the Bing Ads system, we conducted an RCT to randomly expose the searchers for pro-ana content to 10 different ads referring people to one of the three websites: the National Eating Disorders Association, the National Institutes of Mental Health, and MyProAna. MyProAna is a pro-ana website that was found in a previous study to be associated with less pathological online behaviors than other pro-ana websites. We followed participants exposed and unexposed to the ads to explore their past and future online searches. The ads were shown 25,554 times and clicked on 217 times. Results: Exposure to the ads was associated with a decrease in searches for pro-ana and self-harm content. Reductions were greatest among those referred to MyProAna (reduction of 34.0% [73/215] and 37.2% [80/215] for pro-ana and self-harm, respectively) compared with users who were referred elsewhere (reduction of 15.47% [410/2650] and 3.21% [85/2650], respectively), and with users who were not shown the ads, who increased their behaviors (increase of 57.12% [6462/11,314] and 4.07% [461/11,314], respectively). In addition, those referred to MyProAna increased their search for treatment, as did control users, who did so to a lesser extent. However, users referred elsewhere decreased their searches for this content. Conclusions: We found that referring users interested in ED-related content to specific pro-ana communities might lessen their maladaptive online search behavior. This suggests that those who are preoccupied with EDs can be redirected to less pathological online searches through appropriate pathways. Trial Registration: ClinicalTrials.gov NCT03439553; https://clinicaltrials.gov/show/NCT03439553 (Archived by WebCite at http://www.webcitation.org/6xNYnxYlw) UR - http://mental.jmir.org/2018/1/e6/ UR - http://dx.doi.org/10.2196/mental.8212 UR - http://www.ncbi.nlm.nih.gov/pubmed/29472176 ID - info:doi/10.2196/mental.8212 ER - TY - JOUR AU - Syed-Abdul, Shabbir AU - Fernandez-Luque, Luis AU - Jian, Wen-Shan AU - Li, Yu-Chuan AU - Crain, Steven AU - Hsu, Min-Huei AU - Wang, Yao-Chin AU - Khandregzen, Dorjsuren AU - Chuluunbaatar, Enkhzaya AU - Nguyen, Anh Phung AU - Liou, Der-Ming PY - 2013/02/13 TI - Misleading Health-Related Information Promoted Through Video-Based Social Media: Anorexia on YouTube JO - J Med Internet Res SP - e30 VL - 15 IS - 2 KW - Medical Informatics KW - Internet KW - Online videos KW - YouTube KW - Eating Disorder KW - Anorexia Nervosa KW - Social Network N2 - Introduction: The amount of information being uploaded onto social video platforms, such as YouTube, Vimeo, and Veoh, continues to spiral, making it increasingly difficult to discern reliable health information from misleading content. There are thousands of YouTube videos promoting misleading information about anorexia (eg, anorexia as a healthy lifestyle). Objective: The aim of this study was to investigate anorexia-related misinformation disseminated through YouTube videos. Methods: We retrieved YouTube videos related to anorexia using the keywords anorexia, anorexia nervosa, proana, and thinspo on October 10, 2011.Three doctors reviewed 140 videos with approximately 11 hours of video content, classifying them as informative, pro-anorexia, or others. By informative we mean content describing the health consequences of anorexia and advice on how to recover from it; by pro-anorexia we mean videos promoting anorexia as a fashion, a source of beauty, and that share tips and methods for becoming and remaining anorexic. The 40 most-viewed videos (20 informative and 20 pro-anorexia videos) were assessed to gauge viewer behavior. Results: The interrater agreement of classification was moderate (Fleiss? kappa=0.5), with 29.3% (n=41) being rated as pro-anorexia, 55.7% (n=78) as informative, and 15.0% (n=21) as others. Pro-anorexia videos were favored 3 times more than informative videos (odds ratio [OR] 3.3, 95% CI 3.3-3.4, P<.001). Conclusions: Pro-anorexia information was identified in 29.3% of anorexia-related videos. Pro-anorexia videos are less common than informative videos; however, in proportional terms, pro-anorexia content is more highly favored and rated by its viewers. Efforts should focus on raising awareness, particularly among teenagers, about the trustworthiness of online information about beauty and healthy lifestyles. Health authorities producing videos to combat anorexia should consider involving celebrities and models to reach a wider audience. More research is needed to study the characteristics of pro-anorexia videos in order to develop algorithms that will automatically detect and filter those videos before they become popular. UR - http://www.jmir.org/2013/2/e30/ UR - http://dx.doi.org/10.2196/jmir.2237 UR - http://www.ncbi.nlm.nih.gov/pubmed/23406655 ID - info:doi/10.2196/jmir.2237 ER - TY - JOUR AU - ter Huurne, D. Elke AU - Postel, G. Marloes AU - de Haan, A. Hein AU - Drossaert, H.C Constance AU - DeJong, A.J Cor PY - 2013/02/04 TI - Web-Based Treatment Program Using Intensive Therapeutic Contact for Patients With Eating Disorders: Before-After Study JO - J Med Internet Res SP - e12 VL - 15 IS - 2 KW - Eating disorders KW - eHealth KW - Internet KW - Web-based treatment KW - Intensive therapeutic contact KW - Program evaluation KW - Treatment effectiveness. N2 - Background: Although eating disorders are common in the Netherlands, only a few patients are treated by mental health care professionals. To reach and treat more patients with eating disorders, Tactus Addiction Treatment developed a web-based treatment program with asynchronous and intensive personalized communication between the patient and the therapist. Objective: This pilot study evaluated the web-based treatment program using intensive therapeutic contact in a population of 165 patients with an eating disorder. Methods: In a pre-post design with 6-week and 6-month follow-ups, eating disorder psychopathology, body dissatisfaction, Body Mass Index, physical and mental health, and quality of life were measured. The participant?s satisfaction with the web-based treatment program was also studied. Attrition data were collected, and participants were classified as noncompleters if they did not complete all 10 assignments of the web-based treatment program. Differences in baseline characteristics between completers and noncompleters were studied, as well as reasons for noncompletion. Furthermore, differences in treatment effectiveness, treatment adherence, and baseline characteristics between participants of the three major eating disorder diagnostic groups EDNOS (n=115), BN purging (n=24), and BN nonpurging (n=24) were measured. Results: Of the 165 participants who started the web-based treatment program, 89 participants (54%) completed all of the program assignments (completers) and 76 participants (46%) ended the program prematurely (noncompleters). Severe body dissatisfaction and physical and mental health problems seemed to have a negative impact on the completion of the web-based treatment program. Among the participants who completed the treatment program, significant improvements were found in eating disorder psychopathology (F=54.6, df = 68, P<.001, d=1.14). Body dissatisfaction, quality of life, and physical and mental health also significantly improved, and almost all of these positive effects were sustained up to 6 months after the participants had completed the web-based treatment program. Body Mass Index improved only within the group of participants suffering from obesity. The improvement in eating disorder psychopathology occurred in all three eating disorder diagnostic groups, and the percentage of completers did not differ significantly between these groups. Participants? satisfaction with the treatment program, as well as with their therapist, was high, and participants indicated that they would recommend the program to other patients with eating disorders. Conclusions: The results of this study suggest that the web-based treatment program has the potential to improve eating disorder psychopathology in patients with different types of eating disorders. UR - http://www.jmir.org/2013/2/e12/ UR - http://dx.doi.org/10.2196/jmir.2211 UR - http://www.ncbi.nlm.nih.gov/pubmed/23380291 ID - info:doi/10.2196/jmir.2211 ER -