Eating Disorders


There are common features to all eating disorders (ED). According to the DSM-5 (2013),“feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (American Psychiatric Association, 2022, page 329). As with all disorders, the patient suffers from the disorder, and the first step to getting help is receiving the right diagnosis. Regarding anorexia, binge eating, or bulimia, the DSM-5 classification scheme is mutually exclusive since the disorders differ in clinical course, outcome, and treatment needs. In this research, we looked at anorexia, binge eating, bulimia, OSFED, ARFID, and disordered eating. Anorexia Nervosa, the following there criteria lead to a diagnosis: (1) Restricting food energy intake which results in low body weight,(2) Fear of gaining weight or of becoming fat, (3) The body is perceived as disturbing, and bodyweight and shape have a strong impact on self-evaluation (American Psychiatric Association,2013).


Bulimia Nervosa diagnosis, all of the following criteria need to be present: (1) Recurrent binge eating episodes where (a) larger than average amounts of food are consumed within a timeframe, and (b) lack of control over eating during the episode, (2) Compensatory behaviors to avoid weight gain (e.g., vomiting, use of laxatives). The above-listed behaviors occur at least weekly once for three months. Furthermore, shape and weight heavily impact self-evaluation. The disturbance is not limited to anorexia nervosa episodes (American Psychiatric Association,2013). A binge eating diagnosis requires the presence of recurring episodes where a larger than average amount of food is consumed within a certain time frame, and a lack of control during the episode. Additionally, the individual must have three or more of the following symptoms (a)Eating much more rapidly than normal, (b) Eating until uncomfortably full, (c) Eating large amounts of food when not feeling hungry, (d) Eating alone due to the embarrassment of the amount consumed, and (e) Feeling afterward guilty, disgusted, or depressed. Significant distress about binge eating is present and the behavior occurs at least weekly for three months. Unlike bulimia nervosa, no recurrent use of compensatory behavior (American Psychiatric Association,2013).


OSFED is an umbrella term for eating disorders that cause clinically significant distress without fulfilling the criteria for a specific eating disorder (American Psychiatric Association,2013). To meet the criteria for ARFID one must have an eating or feeding disturbance (e.g., avoidance due to sensory characteristics of food) leading to a failure to meet appropriate nutritional needs that results in significant weight loss and nutritional deficiency, dependence on oral nutritional supplements or enteral feeding, and a negative impact on emotional and psychological well-being (American Psychiatric Association, 2013).Disordered eating is not a diagnosis, but a descriptive phrase given to eating behaviors that don’t meet the American Psychiatric Association’s criteria for eating disorders (American Psychiatric Association, 2013).Since disordered eating can turn into eating disorders, it’s important to scan clients who might beat risk for them. Symptoms of disordered eating are meal skipping, dieting, weight fluctuations, excessive food or exercise rituals, guilt, shame, and preoccupation with food (Barakat et al.,2019




Online counseling intervention for ED


E-mental health treatments and preventative interventions have been proposed as solutions to help-seeking barriers. Online mental health interventions allow clients to access content anonymously from anywhere at any time. For providers, the benefits include reaching a large number of people from different geographical locations. Sophisticated technology also allows for anonymous online screening and real-time symptom monitoring. Additionally, algorithms can tailor digital intervention to users’ needs (Linard on et al., 2020). Regarding the effectiveness of digital preventative programs, Linardo n et al., (2020) discovered in their meta-analysis that digital preventative programs led to a reduction of ED psychopathology, dietary restraint, shape/weight concerns, and thin-ideal internalization.


Historically, it has been hard to meet the demand for eating disorder treatment since it exceeded capacity. The COVID-19 pandemic widened this gap further since during the pandemic the prevalence of eating disorders increased. To close the gap, counselors have turned to telehealth, offering brief versions of evidence-based treatment and supplementing them with guided self-help (Davey et al., 2023).

Regarding the specific modalities that have worked for treating ED, in addition to Cognitive Behavioral Therapy (CBT) which has been long used to treat EDs, third-wave behavioral therapies acceptance and commitment therapy (ACT), compassion-focused therapy (CFT), dialectical behavior therapy (DBT), and mindfulness-based interventions (MBI) have shown promising results due to teaching clients how to regulate their emotions (Buerger et al.,2021).

Barakat et al., (2019) discovered in their meta-analysis that most ED online interventions use CBT as their framework (19 out of 23 included studies). The remaining studies included a combination of psychoeducation, self-monitoring, and motivational interviewing. There searchers (Barakat et al., 2019) reported in their findings that ED online interventions significantly decreased ED behaviors, ED attitudes/beliefs, depression, anxiety, stress, and increased life quality.



The International Journal of Eating Disorders (IJED)


The International Journal of Eating Disorders (IJED) was established by John Wiley &Sons in 1981. IJED is a peer-reviewed medical journal, covering the study of eating disorders and worldwide policy related to eating disorders.


Moreover, the journal accepts manuscripts that contribute to scholarly critique and discussion about the existing literature. According to journal information from the official site of IJED (International Journal of Eating Disorders n.d.), the mission of the journal is to serve as a platform for scientific knowledge required for clinicians and/or future researchers to gain a better understanding of treatment and preventive strategies for eating disorders.


Additionally, the journal includes the interest of patient groups to advocate for people with eating disorders diagnosis. The journal attracts mainstream media outlets as well. All articles in IJED are reviewed through an anonymous, double-blind, peer-review process. Twelve issues are published monthly, including manuscripts covering a wide range of eating disorders, interventions, and assessments.


IJED has welcomed meta-analysis/synthesis articles based on interventions, eating disorders, culture, and other related eating disorders (Dahlenburg, et al., 2019; Schaefer, & Thompson,2018; Yim, & Schmidt, 2019). In this article, the researchers systematically explored articles published between January 2019 to September 2023 which discussed research focused on online delivery modalities (zoom, app, recorded intervention, websites) for preventing and treating eating disorders and disordered eating.


The following research questions were used in the current study (a) How frequently does IJED publish articles during the review period? (b) What are the attributes of the population or sample studied within the articles reviewed in the current study? (c) What are the attributes of interventions and delivery modalities within the articles reviewed? (d) What specific types of eating disorders were studied between the years of 2019 to 2023?




                         












Procedure: inclusion and exclusion criteria



The current study aimed to review the content, methodology, types of eating disorders, and online intervention modalities utilized in the articles published in the IJED between January2019 (volume 52, issue 1) to September 2023 (volume 56, issue 9). The authors referred to Stemler (2001) and McKibben et., (2020) to collect data and synthesize the results. Initially, the second author reviewed the articles of IJED, formed a preliminary content analysis, and consulted the first author. Based on the eating disorder content analysis literature review, the first and second authors discussed the following research criteria: virtual intervention modality, types of eating disorders, target population, sample diversity, and research methodology. Articles were collected and analyzed based on the inclusion criteria (Stemler, 2001).


For the initial review, each article’s title, abstract, and keywords were carefully reviewed to understand whether it met the criteria of being a counseling intervention with online aspects for eating disorders. The keywords included online therapy, e Therapy, digital health technologies, and mobile apps; and the interventions needed to be relevant to mental health counselors.



After the initial review, the researchers read all the selected articles published in the journal to confirm the articles aligned with the study’s purpose. The research team met regularly for discussions to enhance the rigor of the findings. Articles that provided a procedural description for counseling populations with eating disorders via technological tools were included. Whereas articles that talked about how technology impacted eating disorders or how technology could track eating disorders were excluded. Articles that talked about technologies and eating disorders but not counseling interventions were also excluded from the review. The total number of articles based on the selected inclusion and exclusion criteria was 37 out of 941articles that were published in the International Journal of Eating Disorders between January2018 to September 2023.
















In the IJED, a total of 941 articles were published during the selected review period(January 2019 to September 2023). Of these, 37 (4%) articles focused on using telehealth as a modality of delivery for eating disorder interventions. The mean sample size across the 37studies was 330 and ranged from one participant in a case study (Burton Murray et al., 2022) to3, 294 participants (Kim et al., 2022). The mean age was 26.25. The youngest participant was 5and the oldest was 65 years old. While some studies stated how many participants had dropped out, others didn’t clarify this information. Eleven (29.73%) studies had exclusively female participants, two (5.41%) studies had exclusively male participants, four (10.81%) studies had both female and male participants, another four (10.81%) studies had female, male, and nonbinary participants. Finally, sixteen (43.24%) articles didn’t specify the gender breakdown.



The majority of the studies were conducted with White, non-Hispanic participants (77%).With IJED being an international journal, six (16.22%) of the studies were performed in the US,two (5.41%) had participants from the US and Canada, fifteen (40.54%) were performed in othercountries, for example, England (Toro et al., 2023) and Brazil (Almeida et al., 2021), andfourteen (37.84%) studies didn’t specify where they were conducted.


For the methodology, the researchers included quantitative, qualitative, mixed methods(is it a combination of qualitative and quantitative methodology, Creswell, 2017), and conceptualresearch designs. Of the 37 studies, 32 (86.49%) were quantitative, 1(2.70%) used a mixed studydesign, 2 (5.40%) were conceptual, and 2 (5.40%) used an unspecified research design. Theresearchers did not find any qualitative research during the review period.


Table 1 shows that all 37 studies fit the inclusion criteria established by the authors.Fifteen studies (41%) out of the total reviewed articles utilized a telehealth platform whichincluded phone calls or video conferencing as a modality to deliver the intervention. Sevenstudies (19%) used mobile apps; 3 studies (8%) used websites and delivered treatment modulesto the participants, and twelve studies (32%) used a combination of two or more modalitiesincluding apps, websites, social media, or/and telehealth. Table 2 shows the theory used in theintervention and citations of the respective articles from IJED. CBT was used in the majority ofthe articles. Other techniques included, self-compassion, mindfulness, and a few elements ofmotivational interviewing, family-based interventions, DBT, and ACT.





Table 1






 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 































































































Out of the 37 studies that met our research criteria, 15 (40.50%) of articles included acombination of eating disorders that they studied (e.g., AN and BN), 8 (21.60%) studieddisordered eating (e.g., prevention, participants who were at risk for developing an ED, bodydissatisfaction), 5 (13.5%) studied exclusively Anorexia Nervosa (AN), 4 (10.80%), studiedexclusively ARFID, 3 (8.1%) studied exclusively Binge Eating (BED), 1 (2.70%) studiednonspecific Eating Disorders (stating that participants met DSM-5 ED criteria without specifyingwhich one) and 1 (2.70%) was a pilot study. None of the studies looked exclusively at Bulimia(BN). Since these numbers were rounded up, they collectively add up to 99.9% (see graph 1).




Graph 1: Distribution of articles by eating disorder published in IJED since 2019.




























Discussion
                      




In the four years and nine months reviewed, IJED published a large number of articles on different topics, utilizing various research methodologies. In recent years, the journal has welcomed meta-analysis and content analysis reviews, for example, digital intervention and its outcomes (Barakat et al., 2019; Linardon et al., 2020), and self-help computer-based interventions (Yim, & Schmidt, 2019). The presence of telehealth in counseling sessions and intervention has increased in recent years (Barakat et al., 2019), which is evident in the current research where in the year 2019 there were two articles found on the topic, while in 2022 there
were seven. The COVID-19 pandemic has resulted in counselors having to incorporate brief online evidence-based treatments to meet the demand (Davey et al., 2023). Our research demonstrates that a variety of telehealth delivery modalities have been employed for EDs in counseling, including mobile apps, gaming apps, websites, video calls, and social media. For example, Schell et al., (2021) utilized a gaming platform to study the effects on ED and maladaptive eating behavior.




In the literature, there’s mixed evidence showing the effectiveness of online delivery of interventions in treating EDs. Linardon et al., 2020 found that e-therapies are effective in reducing the symptoms of ED psychopathology, dietary restraint, and shape/weight concerns. Other research has found only small effects for CBT-based preventive e-interventions and fewer effects for treatment and relapse prevention for EDs, and thus felt that the value of e-therapy for EDs was uncertain (Loucas et al., 2014).



In the current meta-analysis, we discovered that most studies on ED online intervention used either a telehealth-only platform (41%) or a mixed intervention that included two or more of the following: apps, websites, social media, or telehealth (32%). Like previous research that concluded that the majority of online ED interventions used a CBT framework (Barakat et al., (2019); Linardon et al., (2020)), we saw the same trend in our research with 26 out of the 37 (70.27%) studies included in our review implementing a form of CBT in their intervention. The remaining theories that were used for intervention included self-compassion, self-monitoring,
mindfulness, motivational interviewing, DBT, ACT, and family-based interventions, which align with previously published research (Linardon et al., 2020; Buerger et al., 2021).



The researchers noticed several of the studies described themselves as pilot studies. Some of these pilot studies conducted research (Bohrer et al., 2023), whereas others only talked about the research they intended to perform (Fitzsimmons‐Craft et al., 2023). Yet others (Toro et al., 2022) talked about what they intended to study and submitted later a second article after they completed the study (Toro et al., 2023).


The results of the article gives counselors treating clients diagnosed with eating disorders or individuals who have an unhealthy relationship with body image and food, insight into virtual services available. However, it’s important to acknowledge the potential limitations of this analysis. Firstly, the total number of articles that met our inclusion criteria was 37 out of 941 published in the review period, which is relatively small compared to all the articles published in IJED during the review period, and restricted the researchers’ ability to draw conclusions about interventions and delivery modalities for ED and body image counseling.

Secondly, it is crucial to note that no causal inferences can be drawn from the results. The analysis employed descriptive and thematic coding to summarize trends observed over four years and nine months within IJED without making inferences. Moreover, despite the use of independent coders, there is a possibility of coding errors. This risk is heightened as many articles lacked specificity and clarity in illustrating methodology, research participants, and the type of eating disorder, which required subjective categorization.


The researchers noticed limited information presented by authors on the description, procedure, and protocol of the interventions/online delivery modalities, which should be further explored. Future researchers can investigate the effectiveness of telehealth interventions and different telehealth modalities, including apps, websites, and video conferencing.


Furthermore, among the reviewed articles, few articles listed participant dropout rates. It’s important to know what participant dropout rates are since Linardon et al., (2020) discovered that digital mental health treatment and prevention programs can have dropout rates as high as 40%, which are much higher than dropout rates observed for face-to-face ED-specific treatment
and prevention programs, which range from 5% (Healthy Weight Intervention) to 18% (CBT-E).


Future research could study attrition rates in online treatment and trends of attrition rates by the platform utilized in the study (e.g., telehealth versus app).


Finally, the researchers reviewed conceptual and empirical studies to enhance methodological rigor. Future researchers may consider conducting separate analyses for conceptual and research studies. Given the prevalence of eating disorders and disorder eating,
future research should also examine how effective new online interventions are for the treatment of EDs.









The high risk associated with eating disorders, challenges meeting the demand for treatments, and the impact of the COVID-19 pandemic, have led to an increase in the utilization of telehealth counseling and computer-based interventions (Barakat et al., 2019; Yim & Schmidt, 2019). The outcome of the current meta-analysis aligns with the literature as evidenced by the increase in
number of articles published on the topic in recent years. However, even with the increase, only 4% of the total articles published during the review period focused on using telehealth interventions in the treatment of eating disorders. Findings on the effectiveness of telehealth interventions were varied, however, the increase in utilization of telehealth services in treatment of eating disorders warrants the need for further research on the potential value of these options.













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