Please tell us a little about your study.
My dissertation study, entitled, “Early intervention of eating- and weight-related problems via the Internet in overweight adolescents: A randomized controlled trial,” evaluated the efficacy of an Internet-delivered program targeting weight loss and the reduction of eating disordered behaviors and attitudes in an overweight adolescent sample. The Internet intervention, Student Bodies 2 (SB2), is a 16-week program designed to help overweight adolescents lose weight through healthy weight management skills and increase positive body image. The weekly content on the SB2 website includes basic education, guided behavior modification for weight control, and cognitive exercises for improving body image. SB2 uses gender-specific Internet interfaces for visual appeal (e.g., more feminine/masculine color schemes) and portions of content were written specifically for girls or boys (e.g., media portrayals of attractiveness). Participants were expected to spend 1-2 hours each week and no more than 30 minutes per day using the program. Each week, adolescents were asked to record their food intake, the amount of physical activity attained, and their weekly weight using a private, on-line journaling feature which were displayed in pop-up windows. Additionally, participants were invited to use an on-line body image journal to record triggers to their body dissatisfaction as they learned how to challenge negative thoughts.

What do you feel are the benefits of doing research via the Internet? What about disadvantages?
The Internet circumvents problems of transportation and can involve participants who live in rural areas or other areas where health and psychological services are not easily available. The cost of use and dissemination of an Internet program is minimal and the Internet provides the unique advantage of being accessible at all times. The Internet has the added advantage of providing information and a forum for social support without stigmatization. The Internet provides a safe place for adolescents, who may feel embarrassed about their weight status or other problems, to ask questions, learn more, and get support from others anonymously. Finally, different content can be presented for participants through programmed algorithms, based on level of interest or need.

The Internet as a method of service delivery seems particularly viable in the adolescent population. In the U.S., 70.1% of homes with children have computers and 62.2% have Internet connections (U.S. Department of Commerce, 2001). Youth, in particular, represent the largest proportion of Internet users and most adolescents in the United States use the Internet (75.6% of 14-17 year olds) and email (82.1% of 14-17 year olds). A significant increase in Internet access can be seen across all major ethnic groups, as well.

The Internet holds great promise for eHealth interventions. However, some limitations are evident. Approximately 76% of the participants in my study indicated that they had difficulty completing program activities each week and cited being too busy as the primary reason (43% of participants), and technical problems with their computers or Internet connections as the second most common reason (24% of participants).

On an average week, the adolescents were asked to read approximately 22 brief screens of text, record at least three days of food intake in their Food Journal, record at least 3 entries in their Physical Activity Journal, record their weight once in their Weight Journal, and participate in the discussion group. There were also other journals that the adolescents were encouraged to use frequently, such as the body image journal and a personal goals journal. Overall, these requirements may have been too burdensome for the participants. Future studies should address the low compliance with program components, perhaps by simplifying the program.

Each week, an average of 14% of participants were unable to log on at some point due to technical issues, causing frustration and lowering compliance. Close attention to the reasons for non-compliance each week, obtained through weekly phone contact, could aid in more quickly responding to technical difficulties. In addition, employing a staff member with the technical training to resolve computer-related issues would aid in minimizing the problems that arise with this technology.

Additional concerns about Internet-delivered treatment include maintaining confidentiality and crisis management (Zabinski et al., 2003). It is critical that investigators be conscientious of risk management procedures while using this mode of treatment delivery.

What were the results of the study?
This study, entitled, “Early intervention of eating- and weight-related problems via the Internet in overweight adolescents: A randomized controlled trial,” evaluated the efficacy of an Internet-delivered program targeting weight loss and the reduction of eating disordered behaviors and attitudes in an overweight adolescent sample. The Internet intervention, Student Bodies 2 (SB2), is a 16-week program designed to help overweight adolescents lose weight through healthy weight management skills and increase positive body image. The weekly content on the SB2 website includes basic education, guided behavior modification for weight control, and cognitive exercises for improving body image. Participants were expected to spend 1-2 hours each week and no more than 30 minutes per day using the program. Each week, adolescents were asked to record their food intake, the amount of physical activity attained, and their weekly weight using a private, on-line journaling feature which were displayed in pop-up windows. Additionally, participants were invited to use an on-line body image journal to record triggers to their body dissatisfaction as they learned how to challenge negative thoughts.

A clinical psychology doctoral student moderated the program with close supervision by a licensed clinical psychologist. Each week, the moderator reviewed all of the private journal entries posted by the adolescents and then sent a newsletter via email containing individualized feedback regarding each adolescent’s food, physical activity, and weight journals, as well as any other program activities for the week (e.g., setting goals for reducing sedentary activity). In addition, participants were involved in a moderated, asynchronous group discussion, which was similar to an online bulletin board.

The control group was provided with Typical Care (TC). TC participants were presented with basic information on nutrition and physical activity, but were not given specific instructions on behavior modification. They were told to continue to make visits to their physician as needed. The control group was offered access to the Internet program at the conclusion of the study.

Participants were recruited at two sites (San Diego, CA and St. Louis, MO) and, to date, 61 adolescents (aged 12 to 17-years old) in three separate cohorts have completed the study. There is an additional cohort of 20 adolescents who are still enrolled in the study. The first three cohorts were randomly assigned to the intervention group (n = 32) or control group (n = 29). Participants were, on average, 14 years old (SD = 1.7) and 62% were girls. The adolescents self-identified as White (48%), Black (23%), Hispanic (16%), and “other” (13%). Participants’ body mass indices (BMIs; kg/m2) ranged from 23.67 to 53.40 (M = 34.09, SD = 7.07) and fell between the 89.51st and 99.94th percentiles for their respective age and gender (M = 97.71, SD = 2.51). Assessments were conducted at baseline and at post-treatment, with a retention rate of 95.1% at post-treatment.

It was hypothesized that adolescents participating in SB2 would experience a greater reduction in body mass, body dissatisfaction, and disordered eating behaviors and attitudes compared with adolescents in the TC group. Secondary hypotheses were that SB2 participants would demonstrate increases in physical activity and consumption of fruits and vegetables, and decreases in sedentary activity and consumption of high-fat foods. Further, SB2 participants were hypothesized to demonstrate decreased negative affect and increased health-related quality of life compared with TC participants. Mediators of change in weight status were investigated, as well.

A statistically significant reduction in BMI z-score was found when compared to the TC group, F(1,58) = 6.29, p = .015; Cohen’s d = 0.19. In terms of absolute weight change, SB2 participants lost a mean of 0.2 (SD = 9.2) pounds and the control group gained a mean of 5.1 (SD = 8.4) pounds over the 16-week study period. For the control group, this demonstrates an average weight gain of more than one pound per month and suggests continued weight gain in the absence of intervention. Because many adolescents grew slightly taller during the study period, this translates into a reduction in BMI units in the intervention group (-0.59 ± 1.50) and an increase in BMI units in the control group (0.29 ± 1.31).

No statistically significant differences were noted between groups on measures of eating disordered attitudes and behaviors, with the exception of an increase in dietary restraint in the SB2 group, F(1,55) = 4.88, p = .031, which reflected program recommendations. Interestingly, the percentage of intervention participants who were binge eating decreased from 22% at baseline to 0% at post, in contrast to the percentage of control group participants which decreased from 24% to 21% at post. The lack of statistically significant findings on measures of eating disordered attitudes and behaviors may be due to the fact that many of the adolescents enrolled in the study were not at elevated risk for the development of an eating disorder at baseline. Evaluating the program with a higher-risk population is warranted to better understand the program’s impact on risk for eating disorders in overweight adolescents.

SB2 participants reduced consumption of high-fat foods, F(1,52) = 6.09, p = .017; d = 0.61, and increased eating-related, F(1,58) = 11.34, p = .001; d = 0.94, and physical activity-related cognitive and behavioral skills use, F(1,58) = 7.43, p = .008; d = 0.78. However, none of these variables were shown to be mediators of outcome. SB2 participants also reported reduced stress levels compared to increases in stress in the TC group, F(1,51) = 9.41, p = .003; d = 0.53.

The adolescents’ satisfaction with the program was generally positive. Eighty percent of the participants rated being satisfied or very satisfied with the program. However, compliance with the program components was quite low. Only about 26% of food journals and physical activity journals were completed and the mean percentage of screens viewed was 33% (SD = 27%), despite incentives for participation such as entry into a monthly lottery drawing based on completion of program components.

Seventy percent of the participants reported being satisfied or very satisfied with the discussion group, but the rates of use within the discussion group were low. For instance, more than half of the participants (61.5%) posted fewer than one message per week, making it difficult for a true “discussion” to take place. Furthermore, responses to the question, “How could we improve the discussion group?” on the satisfaction questionnaire included, “I felt I couldn’t connect with the others,” and, “[I wanted] more people to participate.”

To increase online interaction and social support among participants, the use of synchronous chat rooms should be considered. Participants attempted to use the program’s asynchronous group as a real-time chat room by posting short messages, such as, “i was just wondering if anyone was here?” to which other participants would reply, “I’m here” and “u want to talk?”. Some participants even solicited others’ instant messaging user names to use outside of the program (note: contact outside of the program was not allowed). This interest in instant messaging or real-time interaction reflects nationwide trends. In the United States, 74% of adolescents use instant messaging and more adolescents prefer to communicate with friends via instant messaging compared with traditional, asynchronous email (19% versus 8%; Lenhart, Rainie, & Lewis, 2001). This suggests that a synchronous group might be more appropriately matched to adolescents’ interests.

In summary, an Internet-delivered intervention produced a modest reduction in overweight status in adolescent boys and girls, as seen in reduced BMI and BMI z-scores. In comparison, adolescents who received typical care, consisting of educational handouts on nutrition and physical activity, demonstrated maintenance of or a slight increase in overweight status. Although there were no statistically significant improvements in the intervention group on measures of body image and eating disorder symptomatology, results suggest a trend towards improvement in these domains. Overall, these findings suggest the efficacy of a minimally intensive and easily disseminable program and have implications for the early intervention of obesity and eating disorders. Follow-up data is currently being collected, as it will be important to evaluate the longer-term effects of this intervention.

It is important to note that the reduction in overweight using SB2 is less than that of traditional face-to-face programs for overweight adolescents. Similar findings have been demonstrated in adult weight control programs delivered via the Internet (Tate, Wing, & Winett, 2001). The attenuated effects of the intervention must be weighed against the advantage of using the Internet for treatment delivery, which may allow us to reach more adolescents than traditional, resource-intensive, behavioral weight loss programs. The Internet provides a means to decrease the cost of treatment, decrease the possibility of stigma, and to reach people who would otherwise be unable to obtain behavioral weight loss services. Additional research must focus on developing ways to utilize this technology more effectively and cost-comparison studies are needed in order to quantify the contribution of a potentially less-expensive, but also less-intensive, program.

Contact:
Please contact Angela Celio Doyle, Ph.D., for more information at acdoyle@uchicago.edu.

Acknowledgements
This research was made possible through a Graduate Student Research Award from the American Psychological Association’s Division 38 and funding from RGA/Washington University’s Longer Life Foundation. Collaborators on this study include Drs. Denise E. Wilfley, C. Barr Taylor, Andy Winzelberg, and Brian Saelens. Manuscripts reporting the results from this study are in preparation.

References
Lenhart, A., Rainie, L., & Lewis, O. (2001). Teenage life online: The rise of the instant-message generation and the Internet’s impact on friendships and family relationships. Pew Internet & American Life Project. Washington, D.C.

Tate, D. F., Wing, R. R., & Winett, R. A. (2001). Using Internet-based technology to deliver a behavioral weight loss program. JAMA, 285(9),1172-1177.

U.S. Department of Commerce. A Nation Online: How Americans are Expanding Their Use of the Internet. Washington, DC: Government Printing Office, 2002.

Zabinski, M. F., Celio, A., Wilfley, D. E., & Taylor, C. B. (2003). Prevention of eating disorders and obesity via the Internet. Cognitive Behaviour Therapy, 32,137-150.