A Pilot Study of a Videoconferencing-Based Binge Eating Disorder Program in Overweight or Obese Females

Abstract

Background:

There has been increasing interest in using videoconferencing in health care, but limited research was conducted in Binge Eating Disorder (BED) patients. This 3-month pilot study aimed to assess the feasibility, acceptability, and preliminary efficacy of a videoconferencing (VC)-based treatment program in overweight and obese females with BED.

Methods:

Eighteen participants, aged 20–73, were diagnosed and randomized into either a face-to-face (F2F) group or a VC-based group. In the F2F group, participants received 12 one-on-one weekly counseling sessions from a Licensed Mental Health Counselor and Registered Dietitian Nutritionist. In the VC group, participants received the same counseling through an online telemedicine software. Measured outcomes include retention, adherence to treatment, and attitudinal and behavioral changes of participants.

Results:

In the end of study, of the 9 participants randomized into each group, 8 (88.9%) F2F participants and 4 (44.4%) VC participants completed the study. On average, F2F finishers attended 94.8% of sessions and completed 66.2% of dietary diaries. VC finishers attended 95.8% of sessions and completed 55.4% of diaries. No changes in weight and binge eating episode were observed in either group. F2F finishers had significant improvement on uncontrolled eating (p = 0.01), emotional eating (p = 0.004), food addiction diagnosis (p = 0.04), loss of control (p = 0.04), and clinical significance (p = 0.04). VC finishers observed significant improvements in eating disorder examination shape concern (p = 0.03) and global score (p = 0.03).

Conclusion:

VC-based treatment program is feasible and could be effective for BED patients. Long-term large-scale randomized clinical trials are warranted to further assess the efficacy.

Introduction

Binge eating disorder (BED) is a clinical eating disorder characterized by recurrent binge eating episodes with a sense of loss of control in the absence of compensatory behaviors to counter binge eating occurrences. In the United States, it is the most prevalent eating disorder affecting 2–5% of the general population.¹ According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American women are two times more likely to develop BED in their lifetime than men.² BED is strongly associated with medical and psychological comorbidities, including obesity, type 2 diabetes, heart disease, depression, and substance use disorders. In addition, BED is commonly associated with a lower quality of life.³

Although persons with BED can be normal weight,² BED is frequently seen among those who are overweight and obese. Up to 50% of obese people who pursue weight loss treatment meet criteria for BED.^4,5 This correlation may be due to factors beyond overnutrition. Inhibition of internal signals, such as hunger and satiety, are also characteristic of BED and may contribute to more severe obesity.^6,7 Obese individuals with BED also lose less weight when seeking weight loss treatment compared to those without BED.³ Obese individuals with BED suffer from lower self-esteem, lower self-efficacy, and higher impulsivity than obese individuals without BED.⁶ These comorbidities can antagonize bingeing behavior and reduce the efficacy of traditional obesity treatments, which rarely focus on psychological interventions.⁸

After diagnosis, only 50–63% of eating disorder patients seek treatment for emotional problems.¹ Those who suffer from eating disorders face many hurdles that can prevent them from receiving proper treatment. Moreover, BED treatment requires specialized care, that is, limited in certain geographic locations. Videoconferencing (VC)-based treatment programs present an opportunity to reduce or eliminate some of these barriers to treatment.^9,10

Among BED treatment strategies, cognitive behavioral therapy (CBT) is the first line of treatment for BED.⁸ In treating BED patients, CBT places a primary emphasis on binge eating reduction and a secondary emphasis on weight loss.¹¹ CBT has been incorporated into web-based treatment programs and has shown encouraging results in reducing symptoms of binge eating in studies.^{4,12

–17} However, there is limited research and findings on the VC-based programs in BED patients to our best knowledge.^10,18

Using CBT in BED is evidence-based, however, nutrition rehabilitation is the critical component of the multidisciplinary approach for eating disorder treatment.¹⁹ Nutrition therapy helps restore appropriate nutrition-related parameters since people with BED often have misunderstandings of nutrition. Including a Registered Dietitian Nutritionist (RDN) in the therapeutic process may enhance its overall efficacy.²⁰ The current study included both Licensed Mental Health Counselors (LMHCs) and RDN and thus would provide additional insight into the effectiveness of a multidisciplinary approach to treating BED.

This pilot study aims to assess the feasibility, acceptability, and preliminary efficacy of using a multidisciplinary team against a face-to-face (F2F) control group for an online VC-based BED treatment program. Outcomes of interest include retention, adherence to treatment, participant satisfaction, the attitudinal and behavioral changes of participants, and adequacy of data. Findings from this report can provide insight on the feasibility and efficacy of web-based BED treatment using multidisciplinary teams to either encourage or discourage larger sample pooling.

Methods

Participants

Participants were recruited between fall 2015 and 2016 from North Florida via flyers and electronic announcements at a university, weight loss clinics, fitness centers, and coffee shops. Inclusion criteria were female, age ≥18 years, body mass index (BMI) 25–40, demonstrated BED, and internet access. Exclusion criteria were current bulimia nervosa, substance abuse, suicidal ideation, psychotic disorder, bipolar disorder, serious unstable medical conditions that influence weight or eating, current psychotherapy, antipsychotic or weight-affecting medications, and pregnancy and/or lactation. Participants were required to indicate their informed consent by signing a consent form before administration of questionnaires. This study was approved by the University Internal Review Board Committee.

Study Design and Procedure

This study was a 3-month randomized control trial with a VC-based CBT group and F2F CBT group. After recruitment, a phone prescreening assessed participant eligibility. If the participant indicated suicidal thoughts, a LMHC would contact the participant immediately. Participants who did not meet inclusion criteria were referred to local mental health counseling resources. Participants who met inclusion criteria were scheduled with the LMHC to confirm diagnosis of BED.

An LMHC conducted diagnostic interview with all participants using DSM-5 diagnostic criteria. If the participant met all of the following, she would be confirmed with BED²: (1) recurrent binge eating episodes, (2) three or more associated behaviors, (3) marked distress, (4) binge eating occurs at least once a week for 3 months, and (5) not associated with inappropriate compensatory behaviors. After confirmation of diagnosis of BED, the participants (including one with subsyndromal BED) were then randomized into a treatment group using an online randomization software GraphPad/Quickcalcs.²¹

Conventional F2F group (n = 9): included individual 1-h sessions over 3 months alternating between a LMHC and RDN. In total, participants will have six sessions with LMHC and six sessions with RDN. LMHC sessions included treatment focused on CBT principles and lessons on motivation, binge triggers, automatic thoughts, cognitive restructuring, stress and problem-solving, and assertiveness. RDN sessions included treatment focused on principles and lessons on daily self-monitoring, meal planning, physical activity, mindful eating, exposure to high risk foods, and relapse prevention strategies. These topics were chosen based on Fairburn CBT strategy and previous reports.^13,22
–24 To minimize variability and create a common framework across multidisciplinary staff, a manual of tools, education, and activities to overcome BED was created and used by the study team. The participants also kept a daily self-monitoring diary throughout the program to record meals, binge episodes, hunger levels, and binge triggers. Each LMHC session focused on processing client's binge experiences since last session and utilizing CBT tools and study manual lessons. The RDN would discuss client progress on previously established goals, corresponding lesson from the program, and any available food records. Each of these areas was explored to build-upon prior successes and struggles, with a focus on the current program topic, to progress toward decreasing/eliminating the binge behavior.

VC-based treatment group (n = 9): consisted of the same lessons as FF group, except physical meetings with a LMHC and RDN were replaced by videoconferencing via HIPAA compliant telehealth software, Fruit Street^®. Participants were instructed to upload their self-monitoring diaries and also encouraged to interact with the psychotherapist and RDN to discuss their progresses via emails.

During randomization, demographic data and a series of responses to validated self-reported questionnaires that measured frequency of binge eating behaviors, body weight, eating attitudes, psychological health, goal orientation, and quality of life were collected by research staff. Participants were assigned one of two LMHCs and two RDNs participating in the study. To eliminate disparity, each health professional was paired with one participant in F2F group and one in VC group. In the same treatment group, participants were also equally distributed between health professionals.

Compliance was monitored by attendance. When participants missed more than three appointments with either the RDN or LMHC, or more than four appointments total, they were considered a drop-out. Patient anonymity was preserved through the allocation of numerical study IDs in place of names.

Measurements

Upon randomization into the program, participants completed a set of questionnaires which were readministered upon completion of the program. The following self-report questionnaires were utilized:

Eating disorder symptoms

Eating Disorder Examination Questionnaire (EDE-Q) 6.0 is a well-established self-report instrument assessing the psychopathology associated with the diagnosis of an eating disorder.²³ It measures restraint, eating concern, shape concern, and weight concern, along with objective binge episodes and a total score.²³

Eating Attitude Test (EAT)-26 is a widely used 26-item screening tool that assesses dieting, bulimic and food preoccupation, and oral control.²⁵ Subjects who score ≥20 have an increased risk for eating disorders.²⁶

Three-Factor Eating Questionnaire (TFEQ)-R18 is an 18-item self-assessment tool that measures cognitive restraint, uncontrolled eating, and emotional eating.²⁷ Higher scores are associated with higher BMI²⁸ and/or binge eating.²⁹

Yale Food Addiction Scale (YFAS) is a 27-item tool that assesses signs of substance dependence such as tolerance, withdrawal, and loss of control in eating behaviors and attitudes about food.³⁰ Food addiction was assessed using both a symptom count score and a dichotomous diagnostic score.³¹ Higher YFAS scores are associated with obesity and binge eating.³²

Psychological health

Symptom Checklist (SCL)-90R (90 Revised) is a 90-item self-report instrument to assess a broad range of psychological problems and symptoms of psychopathology, including somatization, obsessive-compulsive behaviors, depression, and anxiety.^33,34 Global indices assessed in this study included Global Severity Index (GSI), Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST). Higher scores indicate higher overall psychological distress.

Beck Depression Inventory (BDI)-II is a 21-item self-report inventory of depressive symptoms. Calculated total scores range from 0 to 13 (minimal depression), 14 to 19 (mild depression), 20 to 28 (moderate depression), and 29 to 63 (severe depression).³⁵

Quality of life

Impact of Weight on Quality of Life (IWQOL)-Lite (short form) is a validated, 31-item self-report measure of obesity-specific quality of life. It assesses physical function, self-esteem, sexual life, public distress, and work and a total score. Higher scores indicate better quality of life.³⁶

Compensation

As compensation for their time, participants had the potential to earn up to three gift cards (valued at 30 dollars each) as they progressed through the study: randomization, week 7, and week 12.

Statistical Analysis

The planned sample size (n = 9–10/group) is appropriate for a pilot study, that is, focused on the feasibility and development of online intervention techniques, and adequate for finding preliminary significant differences.³⁷

Data were screened for normality using Shapiro–Wilk test. Most data stood normally distributed except for baseline data (F2F: BEE, EDEBEE, EATORAL, TFEQEMO, YFAS;VC: EATORAL, TFEQEMO, and IWQOLWK) and 3-month data (F2F: BEE, EATBUL, EATORAL, EATTOL;VC: EDEBEE, EDERS, EATBUL, and IWQOLWK). However, given the small sample size in each group and unequal sample size between groups, nonparametric Wilcoxon Rank Sum test was used to compare pre- and postdifferences within each group and Mann–Whitney test was used to compare baseline data between two groups for continuous variables. Chi-square test was used to compare within and between group differences for categorical variables.

There were no missing data for all finishers. To compare treatment difference between the VC group and F2F group, the changes in pre- and postassessment measures in each group were obtained and compared using Mann–Whitney test for continuous variables and chi-square tests for categorical variables. All data were analyzed with SAS 9.4 for Windows (SAS Institute, Inc., NC). Level of significance was set as α = 0.05.

Results

Participants Flow and Profile

Of the 64 respondents screened for eligibility, 18 were randomized into treatment groups. Of the nine participants randomized into each group, 8 (88.9%) in the F2F group and 4 (44.4%) in the VC group completed the 3-month study. The participant with subclinical BED in VC group dropped out and was not included in the final analysis. Detailed participant flow is listed in Figure 1.

Fig. 1.

Participants flow.

Table 1 presents the demographic profile of participants. There were no differences between the two treatment groups in age, weight, BMI, initial binge eating episode, race, education status, profession, and marital status. The initial average binge eating episode before the study was 11.9 times per 28 days in F2F group and 11.5 times per 28 days in VC group (p = 0.35). The initial average BMI was 34.0 in FF group and 31.8 in VC group (p = 0.37). There were also no differences identified in eating disorder symptoms, psychological health, quality of life, and measurements related to eating attitudes and behaviors between two groups at baseline.

Table 1.

Demographic Profile of Participants

	F2F (N = 8)	VIDEOCONFERENCING (N = 4)	P
Age (year)	37 ± 18.7	32 ± 15.2	0.60
Weight (lbs)	194.2 ± 30.5	189.1 ± 20.6	0.93
Height (in)	63.3 ± 2.8	64.6 ± 2.5	0.65
BMI	34.0 ± 4.7	31.8 ± 2.1	0.37
Binge eating episode (/week)^a	2.3 ± 2.1	2.3 ± 0.7	0.29
Race			0.31
Caucasian	5 (62.5%)	3 (75%)
Africa American	2 (25%)	0 (0%)
Hispanic	1 (12.5%)	0 (0%)
Asian	0 (0%)	1 (25%)
Educational status			0.44
Associate or below	4 (50%)	1 (25%)
Bachelor	3 (37.5%)	3 (75%)
Master or above	1 (12.5%)	0 (0%)
Professional status			0.47
Employed	4 (50%)	2 (50%)
Unemployed or retired	2 (25%)	0 (0%)
Student	2 (25%)	2 (50%)
Marital status			0.68
Single	3 (37.5%)	2 (50%)
Married	5 (62.5%)	2 (50%)
BED diagnosis (%)	8 (100%)	4 (100%)	1.00
EDE-Q
Binge eating episode (/28days)	11.9 ± 15.2	11.5 ± 2.4	0.35
Restraint	2.6 ± 1.6	2.5 ± 0.5	0.97
Eating	2.6 ± 1.5	3.3 ± 1.0	0.60
Shape	4.3 ± 1.5	5.01 ± 0.4	0.80
Weight	3.8 ± 1.3	4.4 ± 0.7	0.37
Global	3.3 ± 1.4	3.8 ± 0.4	0.68
EAT-26 dieting	11.6 ± 5.6	14.0 ± 7.6	0.60
Bulimia	4.0 ± 3.9	6.8 ± 2.8	0.22
Oral control	0.5 ± 1.1	1.0 ± 1.2	0.43
Total score	16.1 ± 9.1	21.8 ± 10.1	0.30
≥20 (%)	3 (37.5%)	2 (50%)	0.68
TFEQ-R18 restraint	13.8 ± 1.8	15.3 ± 2.2	0.30
Uncontrolled eating	28.5 ± 3.7	28.5 ± 5.7	1.00
Emotional eating	11.3 ± 1.0	11.2 ± 1.5	0.87
YFAS symptom count	5.0 ± 2.27	5.3 ± 1.26	0.99
FA diagnosis	5 (62.5%)	3 (75%)	0.67
BDI mean score	18.3 ± 14.6 (mild)	16.5 ± 11.2 (mild)	0.85
SCL-90R GSI	0.96 ± 0.60	1.26 ± 0.88	0.57
PST	44.5 ± 20.23	55.25 ± 26.9	0.54
PSDI	1.78 ± 0.44	1.87 ± 0.53	0.81
IWQOL physical function	75.6 ± 20.5	73.9 ± 17.8	0.96
Self-esteem	36.2 ± 32.3	26.8 ± 18.6	0.77
Sex life	64.8 ± 27.1	82.8 ± 13.9	0.26
Public distress	82.5 ± 16.5	71.3 ± 24.6	0.48
Work	82.8 ± 16.6	71.9 ± 43.8	0.88
Total score	67.3 ± 17.7	63.7 ± 18.2	0.93

Data are presented as mean ± standard deviation for continuous variables or number (%) for categorical variables.

Binge eating episode data were from psychotherapist initial assessment note.

BDI, Becker Depression Inventory; BED, binge eating disorder; BMI, body mass index; EAT-26, Eating Attitude Test-26; EDE-Q, Eating Disorder Examination Questionnaire; F2F, face-to-face; FA, Food Addiction; GSI, Global Severity Index; IWQOL, Impact of Weight on Quality of Life; PSDI, Positive Symptom Distress Index; PST, Positive Symptom Total; SCL-90R, Symptom Checklist-90 Revised; TFEQ-R18, Three-Factor Eating Questionnaire-18; YFAS, Yale Food Addiction Scale.

Adherence to Program

Adherence to the program was measured by number of attended sessions and dietary diaries completed in the current study. Among 8 completers in F2F group, 5 participants (62.5%) attended all 12 sessions, 2 participants (25%) attended 11 sessions, and 1 participant (12.5%) attended 10 sessions. Among 4 completers in WB group, 3 participants (75%) attended all 12 sessions, and 1 participant (25%) attended 10 sessions. In F2F group, diaries completed ranged from 18 to 84 days, with a mean of 55.6 (standard deviation [SD] = 21.6). In VC group, diaries completed ranged from 7 to 71 days, with a mean of 46.5 (SD = 30.1). On average, F2F participants attended 94.8% of sessions and completed 66.2% of dietary diaries. VC participants attended 95.8% of sessions and completed 55.4% of dietary diaries.

Evaluations of Program from Participants

Participants were asked to evaluate on six questions about the program (concern from personnel, adequacy of information about the study, questions satisfactorily answered, personnel knowledgeable and professional, feel they learned from the study, and overall a positive experience). Out of eight completers in the F2F group and out of four completers in the VC group, all participants (100%) in both groups answered either strongly agree or agree to all six questions. Two additional questions on website experience were asked to participants in VC group: IT expertise level and website ease of use. Three participants (75%) rated their IT level as expertise, 1 (25%) as experienced. One participant (25%) rated their first-time website experience super easy, two participants (50%) as easy, and 1 (25%) as neutral.

Open-ended questions were also asked on satisfaction about the program, LMHC, and dietitian. The responses were mostly positive. In brief, most or all participants reported that the program and their counseling sessions were “good,” “great,” “helpful,” “informative,” and/or “supportive.” They were able to integrate better eating habits into their lives and having better control and understanding of triggers/stressors regarding binge eating. Two participants mentioned the ease of online counseling as their favorite component. Most participants did not have difficulty scheduling weekly appointments, but some reported life, school, and work as interfering factors. Food diary was reported as least helpful component by one participant.

Preliminary Treatment Effects of Program

At the end of the program, there were no significant changes in binge eating episode, body weight, and BMI pre- and posttreatment in both groups. There were no group differences in changes of weight, BMI, and binge eating episodes at the end of program either (Table 2).

Table 2.

Preliminary Treatment Effects on Weight and Binge Eating Episodes

	F2F (N = 8)				VIDEOCONFERENCING (N = 4)				P-VALUE (BETWEEN GROUPS)
	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	P-VALUE (BETWEEN GROUPS)
Body weight (lbs)	194.2 ± 30.5	194.3 ± 34.3	0.1 ± 10.7	0.86	189.1 ± 20.6	192.5 ± 24.6	3.4 ± 6.0	0.69	0.78
BMI	34.0 ± 4.6	34.1 ± 5.6	0.0 ± 1.9	0.94	31.8 ± 2.1	32.3 ± 2.8	0.6 ± 1.0	0.69	0.78
EDE-Q BEE	11.9 ± 15.2	4.6 ± 4.5	−7.3 ± 16.4	0.34	11.5 ± 2.4	6.0 ± 9.4	−5.5 ± 7.8	0.29	0.65

Data are presented as mean ± standard deviation.

EDE-Q BEE, binge eating episode from Eating Disorder Examination Questionnaire (times per 28 days).

In terms of eating disorder symptoms, there were no group differences in almost all domains except EDE shape (p = 0.01) and EDE global (p = 0.03) concerns between FF and VC groups (Table 3). When comparing before and after treatment within each group, significant improvements were observed in VC group on EDE shape (p = 0.03) and EDE global score (p = 0.03). In FF group, significant improvements were observed on TFEQ uncontrolled eating (p = 0.01), TFEQ emotional eating (p = 0.004), YFAS diagnosis (p = 0.04), YFAS loss of control (p = 0.04), and clinical significance (p = 0.04).

Table 3.

Preliminary Treatment Effects on Eating Disorder Examination Questionnaire, Eating Attitude Test, Three-Factor Eating Questionnaire, and Yale Food Addiction Scale

	F2F (N = 8)				VIDEOCONFERENCING (N = 4)				P-VALUE (BETWEEN GROUPS)
	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	P-VALUE (BETWEEN GROUPS)
EDE (norms)
Restraint (1.251)	2.6 ± 1.6	1.8 ± 1.0	−0.8 ± 1.7	0.31	2.5 ± 0.5	1.3 ± 1.0	−1.3 ± 0.6	0.17	0.61
Eating (0.624)	2.6 ± 1.5	1.7 ± 1.2	−0.9 ± 1.5	0.29	3.3 ± 1.0	1.6 ± 1.3	−1.7 ± 1.1	0.11	0.21
Shape (2.149)	4.3 ± 1.5	3.8 ± 1.6	−0.5 ± 1.1	0.49	5.0 ± 0.4	2.8 ± 0.8	−2.3 ± 0.4	0.03	0.01
Weight (1.587)	3.8 ± 1.3	3.6 ± 1.5	−0.2 ± 1.2	0.99	4.4 ± 0.7	2.7 ± 0.9	−1.8 ± 0.9	0.06	0.10
Global (1.554)	3.3 ± 1.4	2.7 ± 1.1	−0.6 ± 0.9	0.51	3.8 ± 0.4	2.0 ± 0.7	−1.7 ± 0.5	0.03	0.03
EAT-26
Dieting	11.6 ± 5.6	8.1 ± 5.3	−3.5 ± 6.7	0.14	14.0 ± 7.6	6.0 ± 3.8	−8.0 ± 4.1	0.14	0.23
Bulimia	4.0 ± 3.9	2.3 ± 3.8	−1.8 ± 3.0	0.32	6.8 ± 2.8	2.5 ± 3.7	−4.3 ± 5.3	0.17	0.35
Oral control	0.5 ± 1.1	0.9 ± 1.0	0.4 ± 1.2	0.41	1.0 ± 1.2	1.0 ± 0.8	0.0 ± 1.4	1.00	0.63
Total score	16.1 ± 9.1	11.3 ± 8.5	−4.9 ± 9.5	0.29	21.8 ± 10.1	9.5 ± 5.9	−12.3 ± 6.1	0.20	0.14
EAT score ≥20 (%)	3 (37.5%)	2 (25%)	−1 (−12.5%)	0.59	2 (50%)	0 (0%)	−2 (−50%)	0.10	0.27
TFEQ-R18
Cognitive restraint	13.8 ± 1.8	14.8 ± 3.6	1.0 ± 4.1	0.62	15.3 ± 2.2	17.0 ± 2.8	1.8 ± 2.8	0.80	0.65
Uncontrolled eating	28.5 ± 3.7	22.4 ± 4.6	−6.1 ± 4.8	0.01	28.5 ± 5.7	21.8 ± 4.4	−6.8 ± 4.0	0.09	0.99
Emotional eating	11.3 ± 1.0	8.6 ± 1.9	−2.6 ± 1.5	0.004	11.3 ± 1.5	9.3 ± 2.2	−2.0 ± 1.6	0.26	0.54
YFAS (norms or range)
Symptom count (0–7)	5.0 ± 2.27	3.3 ± 2.1	−1.8 ± 1.8	0.20	5.3 ± 1.3	3.5 ± 1.3	−1.8 ± 2.2	0.20	1.00
FA diagnosis (11.6%)	5 (62.5%)	1 (12.5%)	—	0.04	3 (75%)	1 (25%)	—	0.16
Loss of control (21.7%)	5 (62.5%)	1 (12.5%)	−4 (50%)	0.04	1 (25%)	0 (0%)	−1 (25%)	0.29	0.46
Have tried unsuccessfully (71.3%)	8 (100%)	7 (87.5%)	−1 (12.5%)	0.30	4 (100%)	4 (100%)	0 (0%)	1.00	0.46
Large amount of time spent (24%)	5 (62.5%)	2 (25%)	−3 (37.5%)	0.13	2 (50%)	1 (25%)	−1 (25%)	0.47	1.00
Important activities given up (10.3%)	4 (50%)	2 (25%)	−2 (25%)	0.30	4 (100%)	3 (75%)	−1 (25%)	0.29	0.10
Continued despite problems (28.3%)	7 (87.5%)	5 (62.5%)	−2 (25%)	0.25	3 (75%)	3 (75%)	0 (0%)	1.00	0.67
Tolerance (13.5%)	6 (75%)	6 (75%)	0 (0%)	1.00	4 (100%)	2 (50%)	−2 (50%)	0.10	0.39
Withdrawal (16.3%)	5 (62.5%)	3 (37.5%)	−2 (25%)	0.32	3 (75%)	1 (25%)	−2 (50%)	0.16	0.67
Clinical significance (14.0%)	5 (62.5%)	1 (12.5%)	−4 (50%)	0.04	3 (75%)	1 (25%)	−2 (50%)	0.16	0.58

Bold indicates significant differences (p < 0.05) between pre- and posttreatment within each group or between two treatment groups.

Data were presented as mean ± standard deviation for continuous variables or number (%) for categorical variables.

When assessing effects on psychological health and quality of life, there were no differences between the two treatment groups posttreatment (Tables 4 and 5). After treatment, there were no significant changes observed in pre- and posttreatment in both FF group and VC group.

Table 4.

Preliminary Treatment Effects on Beck Depression Inventory and Symptom Checklist 90 Revised

	F2F (N = 8)				VIDEOCONFERENCING (N = 4)				P-VALUE (BETWEEN GROUPS)
	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	P-VALUE (BETWEEN GROUPS)
BDI
Minimal	3 (37.5%)	4 (50%)	1 (12.5%)	0.09	1 (25%)	3 (75%)	2 (50%)
Mild	2 (25.0%)	1 (12.5%)	−1 (12.5%)		2 (50%)	1 (25%)	−1 (25%)	0.31
Moderate	0 (0%)	3 (37.5%)	3 (37.5%)		0 (0%)	0 (0%)	0 (0%)
Severe	3 (37.5%)	0 (0%)	−3 (37.5%)		1 (25%)	0 (0%)	−1 (25%)
Mean score	18.3 ± 14.6 (mild)	13.0 ± 9.5 (minimal)	−5.3 ± 8.8	0.56	16.5 ± 11.2 (mild)	8.0 ± 5.5 (minimal)	−8.5 ± 5.7	0.34	0.54
SCL-90-R
GSI	1.0 ± 0.6	0.9 ± 0.6	−0.1 ± 0.7	0.74	1.3 ± 0.9	0.8 ± 0.6	−0.5 ± 0.3	0.34	0.28
PST	44.5 ± 20.2	42.4 ± 26.0	−2.1 ± 22.6	0.98	55.3 ± 26.9	41.0 ± 27.2	−14.3 ± 1.5	0.31	0.77
PSDI	1.8 ± 0.4	1.8 ± 0.4	0.0 ± 0.5	0.93	1.9 ± 0.5	1.7 ± .0.3	−0.2 ± 0.5	0.69	0.37

Data are presented as mean ± standard deviation for continuous variables or number (%) for categorical variables.

Table 5.

Preliminary Treatment Effects on Impact of Weight on Quality of Life

	F2F (N = 8)				VIDEOCONFERENCING (N = 4)				P-VALUE (BETWEEN GROUPS)
	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	PRE	POST	CHANGES	P-VALUE (PRE VS. POST)	P-VALUE (BETWEEN GROUPS)
Physical function	75.6 ± 20.5	77.3 ± 15.9	1.7 ± 17.6	0.78	73.9 ± 17.8	83.5 ± 16.8	9.6 ± 4.3	0.40	0.57
Self-esteem	36.2 ± 32.3	41.5 ± 36.7	5.4 ± 15.0	0.80	26.8 ± 18.6	50.8 ± 22.5	24.0 ± 19.6	0.14	0.12
Sex life	64.8 ± 27.1	73.4 ± 27.7	8.6 ± 14.5	0.62	82.8 ± 13.9	78.3 ± 17.9	−4.6 ± 7.7	0.63	0.12
Public distress	82.5 ± 16.5	86.3 ± 17.9	3.8 ± 18.3	0.62	71.3 ± 24.6	71.3 ± 29.5	0.0 ± 14.7	0.97	0.78
Work	82.8 ± 16.6	79.7 ± 20.8	−3.1 ± 25.9	0.90	71.9 ± 43.8	86.0 ± 28.0	14.1 ± 15.8	0.11	0.11
Total score	67.3 ± 17.7	70.5 ± 20.3	3.1 ± 14.3	0.78	63.7 ± 18.2	73.8 ± 20.8	10.0 ± 4.8	0.34	0.35

Data are presented as mean ± standard deviation.

Discussion

This pilot study assessed the feasibility and acceptability of an online VC-based BED program among overweight or obese females with BED. Adherence to treatment and satisfaction of program were evaluated. It also provided preliminary results on the efficacy of the VC-based CBT treatment program to the traditional F2F CBT treatment program using multidisciplinary staff. Suggestions for future studies are proposed.

A noticeable trend from this study was the greater drop-out rate in VC group than the traditional F2F group (55.6% vs. 11.1%). Consistent with other studies, drop-out rates were higher in web-based interventions than in F2F treatments.^38,39 Accounting for the unique drop-out definitions among studies, the rate is higher than some other VC-based treatment programs for addiction or mental health problems, for example, alcohol use disorders (6% after 3 months),⁴⁰ depression (5.7% after 6 months),⁴¹ and opioid treatment program (0% after 3 months).⁴²

After project cessation, staff offered several insights in to this finding. Staff found that body language was not easily observable in online sessions due to visual limitations of videoconferencing. Staff also notices that clients seemed more distracted due to external circumstances in their environment rather than sitting in a therapy office for sessions. In addition, staff in this study reported that therapeutic rapport did not appear as strong with videoconferencing participants, possibly due to the barrier of electronics. In VC group, patients have experienced problems connecting to the online software, especially in the beginning of the program, which might have discouraged participants' motivation. In fact, out of five drop-outs in the VC group, three dropped by week 3.

There were times when technical problems happened, and counselors and participants resorted to phone calls instead of videoconferencing. When participants are responsible for their own equipment and internet, the problem are likely unavoidable.⁴² However, this might be resolved by either conducting counseling sessions at distant sites with equipment and internet supplied by the study or even supplying computers and internet services to participants.⁴² In terms of retention, orientating both study staff and the participant to VC treatment may help reduce drop-out rates by establishing expectations and diminishing nervousness around using web-based interventions.⁴³ This was supported in similar studies. Related investigations with more study staff training reported lower drop-out rates.^12,14,22

Despite high drop-out rate, the programs were well accepted by the finishers. Once participants became comfortable with technology and procedure, they found videoconferencing sessions more convenient. Those who finished either F2F or VC programs demonstrated high adherence to the program (F2F participants attended 94.8% of total sessions and VC participants attended 95.8% of total sessions). On the satisfaction questionnaire participants submitted, they reported that “Online format made it very convenient, study personnel were easy to ask questions.” On the contrary, the adherence to dietary diary was medium or low in the study (F2F participants completed 66.2% of diaries and VC participants completed 55.4% of diaries).

Participants reported on the satisfaction questionnaire that “the food diaries are difficult. On good days, all was fine but I rarely had “good days.” Not overeating, just skipping breakfast, snacking without following the mini meal rule, etc. On those days I just didn't journal and also too busy.” This is not surprising as collecting food journals is well understood as both important and difficult in nutrition research and challenges and barriers have been reported.⁴⁴ For eating disorder patient, the goal of food journal is to identify a food trigger or to understand food habits. Thus, more simplified version of food journal can be considered in future study to improve compliance.

The study did not have many participants to start with, a phenomenon which might partially due to restricted inclusion and exclusion criteria. We only included participants with BMI 25–40. Twenty participants were excluded due to out of range BMI. We also excluded the bulimia nervosa patient (n = 2) in the study. Many studies have found no or little effect on body weight in BED patients treated utilizing CBT.^45
–47 Our study reported the same finding in both groups.

CBT emphasizes the role of the patient's thoughts in affecting their behaviors and focuses on taking control of thoughts to control one's actions and outlook on life.⁴⁸ Thus this therapeutic approach is more likely to produce better outcomes by reducing the impact of their weight on their mental state and quality of life, while also reducing bingeing frequency with significant long-term efficacy, even when weight loss during treatment was not significant.^4,8,22 Videoconferencing CBT might need to be tested with BED patients regardless of weight.

There were trends of reduction or improvement of behavioral and attitudinal binge eating symptoms in both F2F and VC groups, but few scales reached significant levels in the end of 12-week study. For example, both groups experienced nonsignificant reduction in binge eating episode. Several hypotheses surround this phenomenon include the length of treatment delivered and multidisciplinary approach. In other BED studies, researchers established a minimum duration of 4 to 6 months, of weekly treatment.^12,14,22 Among these studies, longer durations of treatment correlated with a better reduction in binge-eating episodes.^14,22 In another videoconferencing BED study that shows binge eating episode reduction, the treatments were 12 to 20 sessions of CBT plus 6–8 nutritional therapies when necessary.¹⁰

In conjunction with this study's small sample sizes, the treatment duration was also the shortest among other studies. A longer duration of treatment may show more promising results, however, similar web studies reducing binge eating episodes in Bulimia Nervosa participants found that web-based treatment against a F2F group was not effective immediately after treatment, but showed continued reduction at the 12-month follow-up.⁴⁹ Therefore, more positive implications may have resulted with longer length of treatment and consequential follow-up.

In addition, the professional composition of study team may have impacted findings. Most other BED treatment studies did not use multidisciplinary staff. Rather, they used counselors and psychologist only to deliver CBT interventions.^12,14,22,50 One study provided nutrition sessions when necessary.¹⁰ The frequency of psychotherapy sessions delivered by LMHC's in this study were significantly less compared to those studies. Although a multidisciplinary approach is recommended and proved to be advantageous and effective in eating disorder treatment,^10,20 it is possible that some participants needed more focus in psychotherapy treatment over nutrition or further investigation into the appropriate frequency of psychotherapy and nutritional sessions may be required.

The significant positive effects on several behavioral and attitudinal symptoms in either F2F or VC groups are consistent with previous report, in which CBT intervention significantly improved eating disorder psychopathology.^13,15,22 More promisingly, the result presented preliminary evidence for promoting clinical improvement via a multidisciplinary videoconferencing program.

This is a pilot study providing evidence on the feasibility and acceptability of a videoconferencing BED treatment program. Some limitations exist in addition to small sample size: survey data are self-reported, which creates potential for socially desirable responses from participants. Longer follow-up findings were not available. The findings cannot be generalized to nonstudied populations (e.g., male participants and population in other demographic areas) either.

Conclusion

VC-based treatment programs were feasible and could potentially be an effective approach for BED patients. The reduction in eating disorder risk and improvement of self-perceived health status can be achieved without a reduction in weight or binge eating episodes. Long-term large-scale randomized clinical trials are warranted to further assess the efficacy of VC-based approaches in treating eating disorders.

Footnotes

Acknowledgment

The authors thank Bridget Stanton for proof-reading and editing the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by University of North Florida U.S. Women and Girls' Health Endowed Research Professorship grant and received complimentary telemedicine software from Fruit Street Company. The founding source had no role in the study design, collection, analysis or interpretation of the data, writing the article, or the decision to submit the article for publication.

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