Which behaviour change techniques make digital interventions for eating disorders effective?

Consuming issues (EDs) are extremely widespread in Western international locations, with current reviews from US knowledge suggesting that, by the age of 40, 1 in 5 ladies and 1 in 7 males will expertise some kind of ED (Ward et al., 2019).

Despite the fact that EDs are linked to excessive psychological and monetary prices, in addition to excessive mortality (Arcelus et al., 2011), it’s estimated that a number of folks with EDs nonetheless don’t obtain the remedy they want (Striegel Weissman & Rosselli, 2017). That’s why digital interventions, with their straightforward, low-threshold entry and low price to the person, are a possible sport changer.

Digital interventions for ED signs are promising (Linardon et al., 2020), however we nonetheless don’t know which elements underlie their effectiveness. Step one to understanding these elements is to determine which behaviour change strategies (BCTs) are included within the interventions. BCTs are the weather designed to alter the processes that result in behaviour – in different phrases, the “lively components” of an intervention (Kok et al., 2016; Michie et al., 2013), reminiscent of giving suggestions or reinforcement.

On this paper, Thomas and colleagues (2024) got down to examine which BCTs are included in efficient digital interventions for EDs.

Consuming issues are on the rise, with knowledge simulations suggesting that 1 in 5 ladies and 1 in 7 males will expertise some kind of consuming dysfunction by the age of 40.

Strategies

Following a well-documented search technique conforming to PRISMA pointers, the authors searched 8 databases and recognized 17 randomised managed trials (RCTs) on digital interventions for adults with mild-to-moderate ED signs.

They coded the interventions for his or her theoretical background utilizing an tailored model of the Principle Coding Scheme; mode of supply utilizing the Mode of Supply Ontology; and their BCTs utilizing the established BCT Taxonomy (Michie et al., 2013). Danger of bias was assessed with the Cochrane Danger of Bias software.

The authors additionally carried out a meta-analysis utilizing a random results mannequin on the effectiveness of the digital interventions, utilizing the Consuming Dysfunction Examination Questionnaire (EDE-Q; Fairburn & Beglin, 2008) as main end result.

Outcomes

Research traits

Of the 17 included research, 12 (71%) in contrast a digital intervention to a waitlist management (WC) or treatment-as-usual (TAU), whereas the opposite 5 (29%) used an lively remedy as management.

The whole pattern throughout research was giant (n = 5,254). Contributors have been between 22.1 and 43.2 years previous on common, and predominantly feminine, with solely two (12%) research together with greater than 10% male contributors. Eight of the 17 research focused folks with any ED signs, whereas six focused binge consuming and three focused bulimia or ED-Not In any other case Specified.

Digital intervention traits

Most (16/17, 94%) research reported that the digital intervention was guided by a particular theoretical background, which principally consisted of Cognitive Behavioural Remedy (CBT) and the transdiagnostic idea of EDs.

The commonest modes of supply have been web sites (11/17, 61%), and fewer typically cell apps (2/17, 12%) or a mixture of the 2 (4/17, 24%). Video or audio functionalities weren’t typically used (<5/17, 29%). Some interventions (4/17, 24%) have been utterly self-guided, however the majority (13/17, 76%) contained some type of human interplay, reminiscent of e-mail check-ins with a therapist.

Behaviour change strategies (BCTs)

Thirty-eight (41%) of the 93 BCTs described within the BCT Taxonomy (Michie et al., 2013) have been recognized throughout interventions. However which BCTs characterised the efficient digital interventions?

Whereas the research can’t pinpoint results to particular BCTs, the authors famous that over three quarters of the digital interventions included the next BCTs:

• Self-monitoring of behaviour (e.g., letting customers hold a meals diary)
• Self-monitoring of outcomes of behaviour (e.g., weekly weight monitoring)
• Suggestions on behaviour (e.g., offering bar charts that visualise customers’ progress)
• Motion planning (e.g., facilitating establishing meal schedules)
• Downside-solving (e.g., offering suggestions for relapse prevention)
• Details about antecedents (e.g., psychoeducation about what could precede an episode).

About half of the efficient interventions additionally included:

• Behavioural observe/rehearsal (e.g., on the premise of made-up eventualities)
• Framing/reframing (e.g., difficult food-related cognitive distortions)
• Prompts/cues (e.g., reminders to document each day progress)
• Publicity (e.g., mirror confrontation workouts).

Effectiveness

The meta-analysis included 10 research (5 for follow-up) and confirmed that the digital interventions have been more practical than ready record management or remedy as typical in decreasing ED behaviours, reminiscent of bingeing and purging. The impact was reasonable, with a imply distinction of -0.57 (95% CI [-0.080 to -0.39]; Z = 4.77, p <.001) in favour of the intervention at post-intervention and -0.33 (95% CI [-0.049 to -0.180; Z = 4.27, p <.001) at follow-up (> 8 weeks; though the authors note some concerns of bias for the follow-up data). Subgroup analyses showed that the digital interventions with the strongest theoretical background were the most effective.

Digital interventions were moderately effective in reducing eating disorders symptoms, compared to waitlist or treatment-as-usual. Over three quarters of the effective interventions contained the same six behavioural change techniques.

Conclusions

According to the authors,

[there] is rising proof for the effectiveness of digital interventions for the remedy of individuals with gentle to reasonable EDs, with improved outcomes at postintervention and sustained outcomes at follow-up.

The efficient interventions appeared to depend on the identical BCTs. Though there is no such thing as a proof that any one of many strategies by itself is liable for the advance in ED symptomatology, the presence of self-monitoring in all interventions means that it’s important in driving change in ED behaviours and will subsequently be thought-about in scientific observe.

Based on Thomas et al. (2024, p. 16), “[effective] digital ED interventions principally used the identical particular [behaviour change techniques] knowledgeable by idea.” This means an necessary avenue for additional investigation.

Strengths and limitations

When deciphering the outcomes of this research, there are some limitations that we want to bear in mind.

First, the meta-analysis solely included 10 research, which restricts its statistical energy. And whereas the pooled pattern was usually giant (> 5000 contributors, with ~2000 included within the meta-analysis) and recruited from the group, the overwhelming majority of contributors have been ladies. As well as, the reviewed research have been carried out in Western international locations, with most not reporting on contributors’ ethnicity. The outcomes could thus not generalise to males, non-binary folks, or non-Western cultures.

Second, drop-out ranged between 6.7% and 58%, and was larger for the digital interventions that included minimal or no therapist help. Whereas 58% could appear excessive, different analyses of person engagement with well-liked psychological well being apps present a drop-out nearer to 90% one month after app set up (Baumel et al., 2019). After all, it’s potential that folks with a sure symptomatology usually tend to interact with digital interventions which can be related to them as in comparison with most people making an attempt out psychological well being apps; nevertheless, drop-out in digital interventions does stay a problem and may weaken the ability of follow-up analyses.

Lastly, as Thomas et al. (2024) additionally point out, it’s not solely clear whether or not the statistically vital results proven within the meta-analysis translate to clinically related outcomes. In different phrases, it’s not clear to what diploma the lower in questionnaire scores has a sensible that means for digital intervention customers.

On the identical time, the research additionally has numerous strengths. The methodology is well-described and thus replicable; there was a excessive inter-rater settlement between the researchers who coded the research; and there was no regarding danger of bias for the post-intervention knowledge. And naturally, the reviewed research have been RCTs, which is the design providing the very best high quality of knowledge on the subject of remedy effectiveness.

As a result of populations of the research included on this systematic overview and meta-analysis, findings could not generalise to males, non-binary folks, and/ or non-Western cultures.

Implications for observe

Digital interventions for numerous situations are right here to remain, and there’s an evolving physique of analysis centered on their effectiveness and the parameters of that effectiveness. This is a crucial subject for us at The Psychological Elf; for instance, we’ve not too long ago blogged a couple of digital intervention for bulimia, and a review of smartphone apps for symptoms of depression and anxiety.

This paper by Thomas et al. (2024) provides to this rising physique of analysis and exhibits that digital interventions can assist lower signs of EDs in adults. The paper additionally highlights smartphone apps, which have been significantly fewer than web sites on this overview, as an necessary avenue for future intervention improvement and analysis.

Importantly, Thomas et al. (2024) transcend effectiveness to additionally have a look at the behaviour change strategies (BCTs) that drive it. This fashion, their paper has necessary implications for the choice of digital interventions to make use of. Therapists of shoppers with EDs, for instance, who want to mix their face-to-face remedy with a digital intervention as a help software, could select web sites or apps that permit shoppers to self-monitor their behaviour – on condition that self-monitoring was a way proven to be persistently current in just about all efficient digital interventions.

As well as, the paper has implications for designers of digital interventions for adults with ED signs, because it factors to BCTs that could be related to incorporate in new interventions. Whereas BCT taxonomies such because the one by Michie et al. (2013), its up to date model (Marques et al., 2023), or various taxonomies (e.g., Kok et al., 2016), are used to code the content material of current interventions, they can be used to information the event of recent interventions. Utilizing such a taxonomy to pick BCTs which can be grounded in idea is more likely to result in higher behaviour change. Sooner or later, it might even be potential to hyperlink BCTs to person profiles (e.g., folks with sure signs or demographic traits) with a purpose to personalise content material and this manner maximise person engagement and – ideally – intervention outcomes.

Improved digital interventions could help face-to-face remedy with a healthcare skilled, or fill the hole till such remedy turns into accessible, with rapid, low-cost and low-threshold intervention. Ideally, they could even result in a lower in signs, such that additional remedy could also be pointless. With the rise in prevalence of EDs and their devastating penalties, this might be particularly related.

Realizing which behaviour change strategies are present in efficient digital interventions makes it simpler to pick digital interventions – both as a therapist or as a consumer.

Assertion of pursuits

This elf has no conflicts of curiosity to report.

Hyperlinks

Major paper

Thomas, P. C., Curtis, Ok., Potts, H. W., Bark, P., Perowne, R., Rookes, T., & Rowe, S. (2024). Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis. JMIR Psychological Well being, 11, e57577.

Different references

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of Common Psychiatry, 68(7), 724–731.

Baumel, A., Muench, F., Edan, S., & Kane, J. M. (2019). Objective user engagement with mental health apps: Systematic search and panel-based usage analysis. Journal of Medical Web Analysis, 21(9), 1–15.

Fairburn, C. G., & Beglin, S. J. (1994). Consuming Dysfunction Examination Questionnaire (EDE-Q). APA PsycTests.

Ferreira, A. J. (2024). Digital self-help for bulimia recovery: encouraging results for waiting list management. The Psychological Elf.

Kok, G., Gottlieb, N. H., Peters, G. J. Y., Mullen, P. D., Parcel, G. S., Ruiter, R. A. C., Fernández, M. E., Markham, C., & Bartholomew, L. Ok. (2016). A taxonomy of behaviour change methods: An Intervention Mapping approach. Well being Psychology Evaluation, 10(3), 297–312.

Linardon, J., Shatte, A., Messer, M., Firth, J., & Fuller-Tyszkiewicz, M. (2020). E-mental health interventions for the treatment and prevention of eating disorders: An updated systematic review and meta-analysis. Journal of Consulting and Medical Psychology, 88(11), 994–1007.

Marques, M. M., Wright, A. J., Corker, E., Johnston, M., West, R., Hastings, J., Zhang, L., & Michie, S. (2023). The Behaviour Change Technique Ontology: Transforming the Behaviour Change Technique Taxonomy v1. Wellcome Open Analysis, 8(Might).

Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J., & Wooden, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medication, 46(1), 81–95.

Striegel Weissman, R., & Rosselli, F. (2017). Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness. Behaviour Analysis and Remedy, 88, 49–64.

Valentine, L. (2024). Apps for depression and anxiety: big new meta-analysis supports effectiveness. The Psychological Elf.

Ward, Z. J., Rodriguez, P., Wright, D. R., Austin, S. B., & Lengthy, M. W. (2019). Estimation of eating disorders prevalence by age and associations with mortality in a simulated nationally representative US cohort. JAMA Community Open, 2(10), 1–12.

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