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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.
This pilot study evaluated the web-based treatment program using intensive therapeutic contact in a population of 165 patients with an eating disorder.
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.
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 (
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.
Approximately 1% of the young female population suffers from bulimia nervosa (BN) and 0.3% from anorexia nervosa (AN). The prevalence of binge eating disorder (BED) is at least 1% of the adult population [
To our knowledge, only three web-based treatments using intensive therapeutic contact have been studied. One intervention included a 3-month email therapy, consisting of one or two emails sent per week by an online therapist [
Despite the mainly positive results of these studies, only the asynchronous, therapist-guided treatment program is available in the Netherlands. The recently published effects of this intervention have been studied in patients with high body dissatisfaction and bulimic symptoms, but not in patients with the different DSM-IV eating disorder diagnoses (AN, BN, and EDNOS, including BED). Patients with AN are even excluded from all three web-based treatments; all that exists is an Internet-based relapse prevention program for AN patients who have already been discharged from in-patient therapy [
The intervention consisted of a website, an online forum, and a web-based treatment program. The website [
The aim of this pilot study was to evaluate adherence to, and the effectiveness of, the web-based treatment program and also patients’ satisfaction with the program and their therapist, respectively. Differences in adherence, appreciation, and the effects of the web-based treatment between patients with a different eating disorder diagnosis were also investigated.
The participants consisted of 165 adults who visited the website [
Homepage of the website.
The structured, two-part, web-based treatment program was based on the principles of cognitive behavioral therapy (CBT) [
The first part of the web-based treatment program included 4 assignments and at least 7 contact moments between the patient and the therapist, focusing on the analysis of the patient’s eating behavior. Patients were asked to register their daily eating behavior, analyze their eating situations, and describe the advantages and disadvantages of their eating problem. At the end of Part 1, the patients received personal advice from their therapist, who in turn obtained expert advice from the multidisciplinary team, which consisted of treatment staff, a doctor specialized in addiction, a psychiatrist, a psychologist, a dietitian, and supervisors. The second part started with setting a goal for eating behavior, exercising patterns, weighing, and compensatory behaviors. This part involved 6 assignments and at least 14 contact moments geared towards helping the patient reach the set goals and desired behavioral change. Examples of the assignments were: changing thought patterns, changing behavior patterns, improving the patient’s self-image, and writing a relapse prevention plan. If patients did not complete all 10 assignments, they were considered to be noncompleters.
All of the therapists involved had a Bachelors degree in nursing or social work or a Masters degree in psychology. All therapists followed an intensive training program that focused on motivational writing skills, the content and implementation of the treatment protocol, and the technical aspects of delivering the intervention. The training program included 2 days of theoretical information and practice-oriented assignments (eg, writing a response to a message received from a patient). After the training program, all therapists went on to complete a full treatment program with a test patient before they could start as an online therapist. They were subsequently supervised for a period of 3 months. If the trainers positively evaluated the therapists at this point, the therapists received a certificate for completing the training program. When the trainers judged a therapist to be unsuitable to work with the web-based treatment program, the training program was terminated prematurely.
Participant's personal online dossier.
Participants completed online self-report measurements at baseline, posttreatment, 6-week and 6-month follow-ups. From the participants who prematurely ended the program, only baseline data were available as the measurement points linked to the treatment sessions.
The primary outcome measure of this pilot study was eating disorder psychopathology, which was assessed by using the Eating Disorder Examination Questionnaire (EDE-Q) [
Secondary outcome measures were Body Mass Index (BMI), body dissatisfaction, physical health, mental health, and quality of life. BMI was measured by dividing the participants’ self-reported body weight in kilograms by the participants’ self-reported height in meters squared. Body dissatisfaction was measured using the 20-item Body Attitude Test (BAT) [
Other measures at baseline included demographic characteristics, motivation for participating in the web-based treatment program, eating disorder diagnosis, previous treatment for eating disorders, and previous treatment for psychological problems. Demographic characteristics included age, gender, level of education, employment, and their daily routine. Participants were categorized as “higher educated” when they had a Bachelors or Masters degree. Participants’ motivation for participating in the web-based treatment program was measured with the question: “Why have you opted for the web-based treatment?” Possible answers were: (1) “I can do this on my own time”, (2) “I can do this from the confines of my own personal environment”, (3) “I can retain my anonymity”, (4) “I prefer contact via the Internet”, (5) “On the advice of a doctor/therapist”, and (6) “For another reason, namely …” (free text response). Eating disorder diagnosis was determined using self-report questions based on the DSM-IV-TR criteria of eating disorders. The MINI-Plus interview [
At posttreatment, participants’ satisfaction with the program and their therapist was measured. Participants were asked which aspects of the treatment program they found most important, as well as how pleasant, personal, and safe they considered the communication with their therapist. Participants were also asked if web-based treatment was effective for them and if they would recommend the intervention to others. Participants had to rate the treatment program and their therapist on a scale from 0 (very low) to 10 (very high). Finally, they also had the possibility of providing additional comments.
A pre-post design was used to compare baseline data with outcome measures after completing the web-based treatment program. Multilevel modeling with SPSS, version 18, was used to determine improvement from baseline to posttreatment for the outcomes of interest. Repeated analyses of the outcome measures allowed for the inclusion of all participants, regardless of missing data, over time. For all outcomes, Cohen’s
We compared baseline characteristics among the three major diagnostic groups: EDNOS, BN nonpurging, and BN purging. Unfortunately, no separate analysis could be conducted for the AN diagnostic group because the pilot study included only 2 participants with AN. The differences between the three diagnostic groups, EDNOS, BN nonpurging, and BN purging, are presented in
Participant characteristics at baseline and differences between diagnostic groups.
Variable | Overall | EDNOSa | BN NPb | BN Pc | Analysis | ||
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n=165 | n=115 | n=24 | n=24 |
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|
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161 (98%) | 111 (97%) | 24 (100%) | 24 (100%) | 1.71 | .43 | |
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35.3 (11.0) | 36.6 (10.2) | 33.1 (11.4) | 30.9 (13.1) | 3.41 | .04 | |
|
113 (68%) | 87 (76%) | 15 (63%) | 11 (46%) | 8.92 | .01 | |
|
69 (42%) | 53 (46%) | 9 (38%) | 6 (25%) | 4.01 | .14 | |
|
123 (75%) | 87 (76%) | 20 (83%) | 15 (63%) | 2.90 | .23 | |
|
90 (55%) | 68 (59%) | 14 (58%) | 6 (25%) | 9.53 | .009 | |
|
108 (65%) | 77 (67%) | 16 (67%) | 13 (54%) | 1.46 | .48 | |
|
29.1 (9.2) | 31.2 (9.4) | 26.4 (6.7) | 22.8 (5.3) | 11.12 | <.001 | |
|
3.4 (1.0) | 3.2 (1.1) | 3.8 (0.9) | 3.8 (0.8) | 5.42 | .005 | |
Restraint | 2.5 (1.6) | 2.1 (1.5) | 3.1 (1.6) | 3.5 (1.3) | 11.22 | <.001 | |
Eating concern | 3.0 (1.3) | 2.8 (1.3) | 3.3 (1.0) | 3.4 (0.9) | 4.14 | .02 | |
Shape concern | 4.3 (1.3) | 4.2 (1.3) | 4.5 (1.2) | 4.3 (1.2) | 0.67 | .51 | |
Weight concern | 4.0 (1.2) | 3.9 (1.2) | 4.3 (1.1) | 4.0 (1.4) | 1.28 | .28 | |
|
60.5 (16.7) | 61.0 (15.8) | 62.1 (16.9) | 55.5 (20.4) | 1.21 | .30 | |
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59.4 (16.6) | 59.1 (16.3) | 67.4 (13.7) | 53.3 (18.5) | 4.61 | .01 | |
|
38.5 (19.8) | 36.6 (20.0) | 36.3 (16.0) | 47.8 (19.7) | 3.42 | .04 | |
|
2.1 (0.5) | 2.0 (0.5) | 2.1 (0.5) | 2.4 (0.5) | 6.33 | .002 |
aEDNOS = eating disorder not otherwise specified.
bBN NP = bulimia nervosa nonpurging.
cBN P=bulimia nervosa purging.
dEating Disorder Examination – Questionnaire (EDE-Q).
eBody Attitude Test (BAT).
fEuroQol-5D visual analogue scale (EQ-5D VAS).
g21-item Depression Anxiety Stress Scale (DASS-21).
hTotal score consisting of Maudsley Addiction Profile Health Symptom Scale (MAP-HSS) and 15 additional eating disorder-specific physical complaints.
More than half of the participants (n=89, 54%) completed all of the treatment sessions (completers), and 118 participants (72%) completed Part 1 of the program.
Participant flow.
We compared baseline characteristics between completers and noncompleters (
Differences in baseline characteristics between completers and noncompleters.
Variable | Completers | Noncompleters | Analysis | ||
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n=89 | n=76 |
|
|
|
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88 (99%) | 73 (96%) | 1.38 | .34 | |
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36.8 (11.2) | 33.5 (10.5) | 1.94 | .054 | |
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65 (73%) | 48 (63%) | 1.85 | .17 | |
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40 (45%) | 29 (38%) | 0.88 | .35 | |
|
75 (84%) | 48 (63%) | 9.63 | .002 | |
|
51 (57%) | 39 (51%) | 0.59 | .44 | |
|
58 (65%) | 50 (66%) | 0.01 | .93 | |
|
28.3 (7.9) | 30.0 (10.5) | -1.19 | .23 | |
|
3.4 (1.0) | 3.5 (1.0) | -0.40 | .69 | |
|
Restraint | 2.6 (1.5) | 2.3 (1.6) | 1.32 | .19 |
|
Eating concern | 2.9 (1.2) | 3.1 (1.3) | -0.88 | .38 |
|
Shape concern | 4.2 (1.3) | 4.4 (1.2) | -0.79 | .43 |
|
Weight concern | 3.9 (1.2) | 4.1 (1.2) | -1.35 | .18 |
|
57.8 (15.6) | 63.8 (17.5) | -2.33 | .02 | |
|
62.2 (14.8) | 56.3 (18.1) | 2.28 | .02 | |
|
34.2 (17.9) | 43.5 (20.8) | -3.10 | .002 | |
|
1.9 (0.5) | 2.3 (0.5) | -4.54 | <.001 |
aEating Disorder Examination – Questionnaire (EDE-Q).
bBody Attitude Test (BAT).
cEuroQol-5D visual analogue scale (EQ-5D VAS).
d21-item Depression Anxiety Stress Scale (DASS-21).
eTotal score consisting of Maudsley Addiction Profile Health Symptom Scale (MAP-HSS) and 15 additional eating disorder-specific physical complaints.
Treatment outcomes for all participants.
Variable | Pretreatment | Posttreatment | Follow-up at 6 months | Overall effecta | |||||||||
|
Mean | SD | MDb | SD |
|
MDb | SD |
|
|
df |
|
Effect sizec | |
|
3.4 | 1.0 | 1.4 | 1.2 | <.001 | 1.2 | 1.4 | <.001 | 54.6 | 68 | <.001 | 1.14 | |
|
Restraint | 2.5 | 1.6 | 0.9 | 1.8 | <.001 | 0.7 | 1.5 | .001 | 11.7 | 70 | <.001 | 0.47 |
|
Eating concern | 3.0 | 1.3 | 1.6 | 1.4 | <.001 | 1.2 | 1.5 | <.001 | 55.6 | 70 | <.001 | 0.95 |
|
Shape concern | 4.3 | 1.3 | 1.6 | 1.5 | <.001 | 1.5 | 1.8 | <.001 | 39.6 | 67 | <.001 | 1.17 |
|
Weight concern | 4.0 | 1.2 | 1.4 | 1.5 | <.001 | 1.3 | 1.6 | <.001 | 41.6 | 68 | <.001 | 1.11 |
|
60.5 | 16.7 | 15.3 | 13.6 | <.001 | 14.5 | 17.1 | <.001 | 40.8 | 67 | <.001 | 0.86 | |
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|
|
|
|
|
|
|
|
|
|
|
|
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< 18.5 | 16.9 | 1.3 | -0.6 | 0.9 | .29 | -0.3 | 0.6 | 1.00 | 3.8 | 9 | .05 | 0.02 |
|
18.5-25 | 21.1 | 1.7 | 0.1 | 1.1 | .99 | 0.7 | 1.8 | .34 | 1.6 | 18 | .22 | 0.39 |
|
25-30 | 27.8 | 1.5 | 0.4 | 1.0 | .66 | 0.7 | 1.9 | .67 | 0.9 | 14 | .48 | 0.46 |
|
> 30 | 36.4 | 7.2 | 1.1 | 1.9 | .01 | 1.5 | 2.1 | .01 | 4.7 | 26 | .01 | 0.20 |
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59.4 | 16.6 | -9.6 | 17.8 | <.001 | -6.8 | 20.5 | .08 | 13.3 | 71 | <.001 | 0.32 | |
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38.5 | 19.8 | 12.8 | 16.1 | <.001 | 11.0 | 17.9 | <.001 | 21.8 | 70 | <.001 | 0.56 | |
|
2.1 | 0.5 | 0.3 | 0.3 | <.001 | 0.2 | 0.3 | <.001 | 36.8 | 67 | <.001 | 0.39 |
aTreatment outcomes were measured with Repeated Measures and Mixed Model analysis.
bMD = Mean Difference; positive MD scores indicate a decrease in baseline scores and negative MD scores indicate an increase in baseline scores.
cEffect sizes were measured with Cohen’s
dEating Disorder Examination – Questionnaire (EDE-Q).
eBody Attitude Test (BAT).
fBMI indexes below 18.5 indicate underweight, 18.5 to 25 healthy weight, 25 to 30 overweight, and over 30 obesity.
gEuroQol-5D visual analogue scale (EQ-5D VAS).
h21-item Depression Anxiety Stress Scale (DASS-21).
iTotal score consisting of Maudsley Addiction Profile Health Symptom Scale (MAP-HSS) and 15 additional eating disorder-specific physical complaints.
Analyses for individual diagnostic groups showed that eating disorder psychopathology significantly improved in the EDNOS group and that this improvement was sustained up to 6 months after completion of the web-based treatment program (
Participants who completed the postassessment (n=86, 52%) were satisfied with the program and the contact they had with the therapist. Most participants (n=72, 84%) found web-based treatment to be an effective method for treating eating disorders and nearly all of the participants (n=78, 91%) stated that they would recommend the program to others. The support of the therapist was considered to be one of the most valuable and important components of the program. Most participants considered the online contact with the therapist to be pleasant (n=77, 90%), personal (n=61, 71%), and safe (n=82, 95%). The assignment “Changing thoughts” and the daily registration in the eating diary were also evaluated as very worthwhile and important. On a scale from 0 to 10, participants evaluated the treatment program with a 7.8 (SD 1.2) and their therapist with an 8.4 (SD 0.9). These evaluations did not differ among the three diagnostic groups (treatment program:
This pilot study showed that the web-based treatment program successfully changed the eating disorder psychopathology in patients with eating disorders and that these improvements were sustained at 6-week and 6-month follow-ups. Participants also indicated that they had become more satisfied with their bodies and that their physical and mental problems had decreased during the treatment program. Participants evaluated the program positively, with the support of the therapist rated as the most important element. Participants experienced the personal online contact with their therapist as pleasant, personal, and safe. On a scale from 0 to 10, they evaluated their therapist with an 8.4.
The improvement in eating disorder psychopathology in our pilot study is consistent with the results of other web-based interventions with intensive therapeutic contact, although our effect sizes seem to be somewhat larger [
The attrition rate in our pilot study was 46%. Because of the linear design of our treatment program, nonusage attrition (program adherence) and dropout attrition (study adherence) were the same in our study. According to a systematic review on adherence to, and the effectiveness of, web-based therapies, it is often difficult to compare the attrition rate of interventions because of the large variation in the reporting of those results [
Completers and noncompleters differed significantly on several baseline characteristics. The baseline physical and mental health as well as participants’ satisfaction with their body seemed to play an important role in completing the web-based treatment program. Although little research has examined differences between completers and noncompleters of treatments for eating disorder patients (especially for web-based treatments), other studies have suggested that the risk of noncompletion increases with an increase in the severity of other health problems and comorbidity [
The web-based treatment was available for patients with all eating disorders; however, as expected based on prevalence rates, most of the participants (70%) fulfilled the criteria for EDNOS (including BED). Almost all of the other participants met the criteria of BN, with half of them belonging to the purging subtype and the other half to the nonpurging subtype. Only 2 participants fulfilled the criteria of AN. The low number of participants with AN can be a result of the recruitment strategy, as it focused on eating disorders in general and not on specific diagnostic groups. In addition, the lower prevalence of AN compared to the other eating disorder diagnostic groups might also be a reason for the limited number of patients with AN in our pilot study. However, the benefits of the web-based treatment program, such as the high degree of anonymity and the increased convenience, are particularly applicable for patients with AN. As such low-threshold forms of treatment for this particular target group are still missing from the current treatment services in the Netherlands, it is important to recruit more patients with AN for the web-based treatment program in the future. However, the recruitment should then be more focused on places where patients with this particular diagnosis can be found (eg, informative websites and forums for patients with AN, patient associations, health centers, general practitioners’ surgeries, and schools), and the message of the recruitment should also be more tailored for this target group.
As the pilot study included only 2 participants with AN, no separate analysis could be conducted for this group. Between the other diagnostic groups (EDNOS, BN purging, and BN nonpurging), we found significant differences regarding several demographic and illness-related variables. The differences in age and employment are not surprising as BN often occurs in young women (some of whom are still studying), while BED has a much broader age range. The differences in BMI and eating disorder psychopathology can be explained by the diagnosis, as participants with BN have compensatory behaviors that are related to body weight and eating disorder psychopathology. The study found no significant differences between the diagnostic groups related to treatment adherence and satisfaction with the program. In addition, eating disorder psychopathology improved within each diagnostic group. Therefore, the web-based treatment program seems feasible for patients with BN, as well as patients with EDNOS, including BED. However, some differences were evident among the diagnostic groups. These differences might be explained by the large differences in numbers between the three groups. It would be interesting to further investigate these differences among larger patient groups in order to draw reliable conclusions.
The pilot study has several limitations. As previously mentioned, almost half of the participants did not complete all of the treatment sessions provided through the program. Consequently, no posttreatment and follow-up data were available from the noncompleters, as these questionnaires were completed after the last treatment session. Therefore, we do not know whether these patients benefited from participating in the treatment program. We have chosen a linear model, as the treatment program is most effective with a specific order of treatment steps, and this model is also useful in working with homework assignments and tailored feedback. However, the lack of information about noncompleters of the intervention is a real disadvantage. We recently started a randomized controlled trial (RCT) to study the efficacy of the web-based treatment program. In the RCT, the web-based application has been modified so that the measurements are no longer linked to the treatment steps. Consequently, posttreatment and follow-up data will be available from both completers and noncompleters. The reasons for noncompletion and the characteristics of noncompleters, as well as their satisfaction with the treatment program and therapist, will also be investigated in the RCT.
Another limitation is that we cannot attribute the observed improvements exclusively to the web-based treatment program due to the nonrandomized design of the study. The RCT will therefore provide more insights into the effectiveness of this intervention. The results and our experiences of this pilot study were the foundation for the development of the RCT. As mentioned before, the web-based application has been modified to differentiate between the research questionnaires and the treatment steps. Study adherence and treatment adherence can therefore be distinguished. In addition, patients with BED will not be included in the EDNOS group in the RCT, but they will comprise an individual diagnostic group based on the BED DSM-IV-TR research criteria. Furthermore, patients with AN and male patients will be excluded, as these groups were a minority in this pilot study and it is not feasible to recruit enough patients within the RCT to be able to make statements about these individual patient groups. However, since the web-based treatment program has been developed for all patients with eating disorders, and we do not want to exclude male patients and AN patients, we will offer them the possibility to participate in the regular treatment program without participating in the RCT. Finally, in the RCT more attention will be paid to completing all research questionnaires to enlarge study adherence. The researcher will actively approach participants via email and phone and will request that they fill in all of the research questionnaires. This will also be stimulated with an incentive of €10.00 for each completed research questionnaire.
A last limitation of this pilot study concerns the reliability of some measurements. Although validated self-report instruments were used, clinical interviews might be more preferable. In addition, a direct measurement of the participants’ height and weight is more desirable than self-reported height and weight [
This pilot study indicated that the web-based treatment program with intensive therapeutic contact is an acceptable intervention for patients with eating disorders. Participants evaluated the program positively, and the results after completing treatment were promising. Eating disorder psychopathology and body satisfaction improved significantly, as did mental and physical health. The web-based treatment program also resulted in an improvement in the quality of life. A randomized controlled trial has recently been started to provide more scientific evidence for the efficacy of this web-based intervention.
Treatment outcomes for individual diagnostic groups.
anorexia nervosa
Body Attitude Test
binge eating disorder
body mass index
bulimia nervosa nonpurging
bulimia nervosa purging
cognitive behavioral therapy
Depression Anxiety Stress Scale
Diagnostic and Statistical Manual of Mental Disorders, 4threvision
Eating Disorder Examination Questionnaire
eating disorder not otherwise specified
EuroQol-5D visual analogue scale
Maudsley Addiction Profile-Health Symptom Scale
motivational interviewing
Mini International Neuropsychiatric Interview Plus
randomized controlled trial
This study was funded by Tactus Addiction Treatment and the Nijmegen Institute of Scientist-Practitioners in Addiction.
None declared.