Using the Internet to Deliver Therapy and Fighting Old Unhealthful Food Patterns

Some Highlights of the AED Meeting

“The toxic food environment in America” is the result of foods that are genetically modified and overprocessed, and the overwhelming financial power of food manufacturers, according to Kelly Brownell, MD, PHD, professor of epidemiology and public health at Yale University. Dr. Brownell was the keynote speaker at the 2005 International Conference on Eating Disorders in Montreal.

Other major factors that contribute to the environment that encourages weight gain, even while appearance standards remain severe, include easy access to high-fat and high-sugar foods, the fact that foods that are convenient and quick to prepare are more often unhealthy than those that take longer to prepare, and the artful promotion of unhealthy foods by food manufacturers, said Dr. Brownell.

Further, a mismatch between spending by the government and private industry has made messages about healthier diets hard to hear, he said. It becomes a matter of money over message when the government spends $3 million to promote healthy eating and “The 5 A Day Program” while McDonald’s spends $500 million promoting far less healthful foods with their slogan, “We love to see you smile.” In addition, many giant food-manufacturing companies heavily subsidize nutrition research, vastly overspending the amounts government agencies can offer, he said.

Marketing unhealthy foods directly to children is another troubling reality in the toxic food environment, said Dr. Brownell. He noted that a new frontier for exploiting children is the cell phone. The Global Positioning Systems (GPS) allow companies to know exactly where a child is at any appointed time, and can direct snack ads directly to them.

Dr. Brownell urged eating disorders specialists and obesity specialists to work more closely to help prevent obesity. The two groups haven’t always worked well together, he said, and the greatest conflict has been over the role of dieting. One problem is that those who treat obesity see dieting as the solution, but dieting is problematic to eating disorders specialists. He suggested that if the two groups collaborated better, it could help prevent both eating disorders and obesity. “Each person in the room can make a more profound effect on improving nutrition than the government can, because real victories occur at the grassroots level, he said.

What can be done?

Individual clinicians can have an impact on healthier lifestyles by taking a number of steps, Dr. Brownell told the audience. First, they can work with the press in their local communities to get information out about healthy eating. Next, they can write to their legislators urging changes in food regulations and content. Third, they can work to change school policies in their own communities, such as getting rid of soft drink machines in schools. Clinicians can also organize groups to protest unhealthy foods in schools.

New Technology Is a Boon to BN Patients

Four presentations at a plenary session on “The Efficacy and Acceptability of New Technologies in the Treatment of Bulimia Nervosa” demonstrated how telemedicine, e-mail, Internet-based self-help programs, and CD-ROM-based cognitive behavioral therapy (CBT) programs may be options for clinicians to reach patients in remote areas or even those individuals who are otherwise unwilling to consult with healthcare professionals.

Dr. James E. Mitchell, chairman and professor at the University of North Dakota School of Medicine and President and Scientific Director of the Neuropsychiatric Research Institute, both in Fargo, ND, told the audience that empirically based psychotherapy programs are not generally widely available, especially in rural parts of the U.S. “Training therapists is impractical, and having therapists travel is not practical and undesirable as most insurance companies will not reimburse a person to drive four hours to treat a person in a rural area,” he said.

Dr. Mitchell and his colleagues recently studied the effects of a telemedicine-based CBT program broadcast to 61 patients. This group was compared with 56 other patients, who received traditional face-to-face therapy. The BN patients were in rural areas of North Dakota and Minnesota. The subjects were randomly assigned to onsite treatment by a traveling therapist sent to the site or to a telemedicine-based CBT. Those who were assigned to the telemedicine group never met the therapist and all work was done over the telemedicine network. All participants received 20 sessions over 16 weeks, and were assessed at 12 weeks and at 52 weeks after the end of treatment. Patients were mostly female, in their late 20s, and almost all were Caucasian.

At the end of treatment, there were no differences in eating concerns, or weight and shape concerns between the two groups. In both groups, baseline values robustly decreased after treatment, especially objective binge eating episodes and vomiting episodes. The group who had face-to-face CBT did have greater reductions in Hamilton depression scores. The total number of binges decreased at about the same rate in both groups. At the end of the study, abstinence rates were 37% in the telemedicine group, compared to 45% in the face-to-face treatment group.

Dr. Mitchell said, “I think we have demonstrated that CBT delivered via a telemedicine network is acceptable to patients; it is roughly equivalent to in-person therapy in terms of all the major outcome variables at follow-up.” He noted that one group that might be particularly difficult to treat with TV-delivered psychotherapy are patients with Axis 2, cluster B personality problems who are more impulsive.

‘You’ve Got Mail’ and Therapy, Too

Dr. Paul Robinson, consultant psychiatrist at the Royal Free Eating Disorders Service, Royal Free Hospital, London, described a pilot program he and his colleagues designed to deliver therapy via e-mail to patients they had never met. Dr. Robinson sent e-mails to 15,000 students inviting them to contact him if they had bulimia nervosa (BN). Fifty-four students responded and 42 appeared to have eating disorders.

The final treatment group included 23 students: 18 had BN, 4 had binge eating disorder (BED), and 1 had an eating disorder not otherwise specified (EDNOS). Information packets were sent to all 23 subjects. Participants kept a diary, and the clinicians (Dr. Robinson and 2 psychiatrists trained in eating disorders) copied the diary, annotated it and sent it back. Two mailings went to each student per week. The clinicians’ e-mail messages also addressed various topics of concern, including advice on depression, physical complications of vomiting, and the need for assessment by the students’ general practitioners.

Dr. Robinson and colleagues randomly assigned the students to one of three groups: e-mail bulimia therapy, 12 weeks of therapy delivered by e-mail (EBT), self-directed writing (SDW), and waiting list control (WLC). WLC subjects were on the waiting list for 12 weeks and then the students were randomly offered EBT or SDW. At 12 weeks subjects were reassessed.

At follow-up, 18.6% of participants had lost their eating disorder diagnosis; there was no change in the control group. EBT was more effective than control in reducing BITE severity scores. When they were first assessed, 83% of the subjects had no prior treatment for their eating disorder. After therapy, 84% of participants reported that they would be willing to undertake further therapy. About half said they would agree to face-to-face therapy, and about half preferred EBT. Overall, about two-thirds of the students agreed they would seek some form of therapy.

Among the few negative comments the researchers received were that the times between e-mails seemed a bit long, even though they heard from the therapists twice a week, and that sometimes the subjects did not receive the e-mails.

Dr. Robinson said some important further issues about e-mail treatment will need to be addressed. For example, there may be malpractice issues and challenges such as liability and insurance coverage. Future studies, looking at manualized EBT and therapeutic writing in greater detail, will be very helpful, he said.

Internet-Based Self-Help for BN

In the third presentation of the plenary session, Tony Lamb, MB, filling in for Fernando Aranda, PhD, of the University of Barcelona, Spain, described the SALUT project, an ongoing multi-country project to investigate ways of applying Internet technology to eating disorders treatment. Dr. Aranda and his colleagues have found that Internet-based therapy programs seem to be an effective approach for treating patients with BN, especially when patients live far from hospital centers or when they do not have the time to come to therapeutic sessions.

The goal of the current study was to see if Internet-Based Therapy (IBT) was effective for reducing symptoms of binge eating and vomiting among BN patients, compared to a standard therapy or a waiting list group. The online study used a CBT self-help guide developed in the SALUT program. The trial had a 6-month cycle: 4 months of self-treatment and 2 months of follow-up. Contact with the therapist included 3 face-to-face evaluation sessions and a short weekly informational e-mail.

The subjects were females from 18 to 30 years of age. Thirty-one patients who received IBT were subsequently compared to two control groups: 31 patients who received brief psychoeducational group therapy, and 31 others who were on a waiting list.

After the patients completed the self-help guide, the frequency of binge-eating was reduced by 79% and the frequency of purging was reduced among 83% of patients. As Dr. Lamb noted, most participants thought the Internet program was easy to use. Other patients liked the fact that although the Internet was private, someone was watching over them and following their progress.

CD-ROM-Based Treatment of BN

Ulrike Schmidt, MD, PhD, of the Eating Disorders Unit at the Maudsley Hospital, London, described her group’s experience with a CD-ROM program based on a CBT model. Their project is a stand-alone program that uses lots of audio clips, audiotapes, and a homework manual. The very interactive program also allows participants to receive personalized feedback. The 8-session program was offered at a pace of one session a week. The first few sessions help participants become oriented to the treatment model and they can individualize it. The later steps are related to learning how to change problematic behaviors, thoughts, and feelings.

Dr. Schmidt and her group examined two cohorts of successive referrals to the Maudsley Hospital. In the first group, participants were given minimal guidance, greeted by researchers who helped them log on, and then at the end of the session they were helped to book another appointment. At all other times, they were left alone in the room with a computer. In the second cohort, researchers added three 20-minute session of therapist support, basically to review how the participants were doing. The participants were quizzed in great detail about how they viewed self-help in general and self-help with a computer using a questionnaire and qualitative reviews.

The results demonstrated in both groups were very comparable-about 80% of the participants who were offered treatment accepted it. According to Dr. Schmidt, this percentage is identical to occasions when her group suggests that a person see a therapist. Those who had guidance with a therapist had slightly better but not significantly different results.

What patients liked best. Patients who liked the program reported feeling mastery over inactivity in their own recovery. The 20% who did not like the CD-ROM program were less positive about the use of self-help for themselves. A survey of therapists in their unit and other eating disorders units around London showed that overall the therapists thought that computerized treatment was much more appropriate for patients with BN than for those with anorexia nervosa. Having familiarity with computerized treatment programs also played a role: those who lacked experience were much more concerned about its limitations, such a lack of tailoring treatment to an individual’s needs or lack of a therapeutic relationship. On the whole, CBT therapists were much more positive about computerized treatment and much less concerned about its limitation, according to Dr. Schmidt.

On the drawing board: a program for patients with anorexia nervosa. Dr. Schmidt and colleagues are developing a CD-ROM program for patients and parents of patients with anorexia nervosa. This program will use a motivational and CBT approach, to help improve communication skills, how to deal with other crises and how to assess risk in their daughter. “Parents often feel very helpless and do not have the skills to deal with the illness,” she said.