Spring 2007 Edition

April 11, 2007

Over the past decade, one aspect of our work has focused on developing a model of providing population-based, Internet-enhanced delivery of universal, targeted and indicated prevention and intervention programs (1-2). We initially focused our work on eating disorders in adolescents and young women because of the high prevalence of eating disorders in the young female population and their negative impact. Our work was facilitated by the identification of modifiable risk factors (3), the availability of effective, structured, manualized interventions for students with subclinical and clinical eating disorders, and reliable outcome measures and diagnoses (1). More recently we have expanded the scope of our interventions for use with male middle school students, individuals without eating disorder risk, and overweight high school students. Figure 1 shows our overall model.

Figure 1

Our general approach has been to use an 8-week structured online program that includes weekly psychoeducational lessons (Figure 2) and activities, body image concern monitoring, journaling and a moderated discussion group. In a series of studies we continued to refine the intervention and eventually demonstrated that the program, StudentBodies™ (SB), was effective in reducing eating disorder (ED) attitudes in a college population while being better received than a face-to-face class (4). This study set the stage for an effectiveness trial in which we randomized 480 college age women with high weight and shape concerns to the SB program or a wait-list control group and followed them for up to three years (5). The intervention significantly reduced weight and shape concerns for up to 2 years and decreased risk for the onset of EDs, at least in some high-risk groups. Combining our effectiveness and efficacy trials, we felt we have developed a program to reduce risk among college-age women. In the meantime, we revised the program to address a somewhat younger population (9-12 grade students) and also demonstrated that it reduced weight and shape concerns in this population (6).

Figure 2

To reach the broader populations of boys and adolescent women without eating disorders, , we refocused our programs to be provided in classrooms. We then demonstrated that the revised program could simultaneously provide universal and targeted programs by sorting female students into risk groups appropriate to their needs (7, 2). To address the issues of making the program applicable for boys and to make our programs salient to schools, we then developed a general health program for boys and girls without eating disorders. In a pilot study, we delivered the program to all eighth-grade students (n = 100) in a public school in Idaho. An Internet-based algorithm sorted female students into two groups based on risk for developing an eating disorder, either low or high risk. Male students participated as one general group. Participants in each group were also assigned to an online discussion group that corresponded to their group assignment and were encouraged to post messages to group members of similar risk. All three groups showed significant increases in knowledge related to the program content and reported increased physical activity levels from pre- to post-intervention. Females in the high-risk group also showed significant reductions in weight and shape concerns. Participants were enthusiastic about using the online health program; almost all reported that they would prefer an online format to a traditional classroom format.

This pilot study in Idaho demonstrated that we could deliver a program to all boys and girls in the same class but we had not yet developed a weight maintenance program. Such a program would increase the public health salience of the program and enhance the relevance of our program for delivery in schools. We then developed a 16 week program designed to promote weight maintenance in students who were at risk of obesity and had episodes of bingeing and/or overeating. This version included additional components such as online weekly food, physical activity, and weight journals and a supplemental hardcopy daily food journal. Figure 3 shows the initial monitoring tool that students were asked to complete and enter into the Student Bodies program.

Figure 3

The program was effective for weight maintenance and reducing binge eating behaviors and weight and shape concern. The study also provided information on the relationship of change in bingeing overeating and weight. For the participants in the treatment group who were engaged in some overeating/bingeing at baseline there was a significant mean decrease in BMI over one year. In contrast, participants who were not engaged in some overeating/bingeing at baseline in the treatment group experienced a mean increase in BMI over one year. The results from this study indicate that weight management and eating disorder psychopathology reduction can be achieved simultaneously using a scalable Internet-delivered program.

We now have a program to provide universal and targeted prevention/intervention for high school students either at risk or not at risk for eating disorders and/or weight gain. However, data from our last study suggested that students were not using many of the features of the program, and adherence was below 50% overall. To examine why adherence was low, we debriefed many of the participants and conducted a survey and a series of pilot studies with same age students. Not unexpectedly, we found that adolescents use a variety of media and much prefer community-based websites, instant and text message to e-mail (and particularly e-mail from adults!), have very limited time for programs, prefer "grazing" to a structured participation, and enjoy creating their own media as part of a program. Internet-based programs may need to include outside structure and contingencies. To this end, our next series of studies will focus on combining online programs with text messaging, classroom mentoring, parental programs and various combinations of site and method of delivery.

We also need to develop and evaluate a number of new program features to achieve our dream of universal, targeted and indicated interventions. We need to implement online screening that identifies clinical populations (9). We also need to implement online interventions for participants with subclinical or clinical problems (2) which will require modifying our basic intervention to address issues such as affect regulation. In such applications, we plan to use computers and the Internet to assist more traditional face-to-face individual and group therapy approaches (10). Finally, we are examining ways of taking full advantage of the unique aspects of the "internet." For instance, we are looking at ways of activating "internet" communities to sustain and expand preventive and targeted interventions.

C. Barr Taylor, MD, & Megan Jones, BA
Laboratory for the Study of Behavioral Medicine
Department of Psychiatry
Stanford Medical Center

Reference List

(1) Taylor CB, Cameron R, Newman M, Junge J. Issues related to combining risk factor reduction and clinical treatment for eating disorders in defined populations. The Journal of Behavioral Health Services and Research 2002; 29:81-90.
(2) Luce KH, Osborne MI, Winzelberg AJ, Taylor CB. Application of an algorithm-driven protocol to simultaneously provide universal and targeted prevention programs. International Journal of Eating Disorders 2005; 37:220-226.
(3) The McKnight Investigators. Risk Factors for the Onset of Eating Disorders in Adolescent Girls: Results of the McKnight Longitudinal Risk Factor Study, American Journal of Psychiatry 2003; 160:248-254.
(4) Celio AA, Winzelberg, AJ, Wilfley DE, Eppstein-Harald D, Springer EA, Dev P, Taylor CB. Reducing risk factors for eating disorders: Comparison of an Internet- and a classroom-delivered psychoeducation program. Journal of Clinical and Consulting Psychology 2000; 68:650-657.
(5) Taylor CB, Bryson S, Luce KH, Cunning D, Celio A, Abascal LB, Rockwell R, Dev P, Winzelberg AW, Wilfley DE. Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry 2006; 63:831-838.
(6) Bruning Brown J, Winzelberg AJ, Abascal LB, Taylor CB. An evaluation of an internet-delivered eating disorder prevention program for adolescents and their parents. Journal of Adolescent Health 2004; 35:290-296.
(7) Abascal L, Brown J, Winzelberg AJ, Dev P, Taylor CB. Combining universal and targeted prevention for school-based eating disorder programs. International Journal of Eating Disorders 2004; 35:1-9.
(8) Jones M, Luce KH, Osborne MI, Taylor K, Cunning D, Celio Doyle A, Wilfley D, Taylor, CB. Reducing Binge Eating and Overweight in Adolescents: A Randomized Controlled Trial. Annals of Behavioral Medicine 2007; 33:SO38.
(9) Jacobi C, Abascal L, Taylor CB. Screening for eating disorders and high risk behavior: Caution. International Journal of Eating Disorders 2004; 36:273-288.
(10) Kenardy JA, Dow MGT, Johnston DW, Newman MG, Thompson A, Taylor CB. A comparison of delivery methods of cognitive behavioral therapy for panic disorder: An international multicenter trial. Journal of Consulting and Clinical Psychology 2003; 71:1068-1075.

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.