Technology x Eating Disorders: One App a Day

A new wave of mobile applications is revolutionising medical care, and now the potential of apps is being applied to treatment for eating disorders such as anorexia, bulimia and binge eating.

By Cristiana Bedei

Pic: "Slidescreen" by Johan Larsson/Flickr under Creative Commons.

From detecting signs of skin cancer to managing episodes of anxiety, the use of mobile applications for treating health conditions is on a rapid rise.

In just over two years, the number of health apps available to download has more than doubled to 100,000 and global use has risen by 62% since last December, confirming a shift towards do-it-yourself resources to make healthy living easier.

The rise of mobile health is driven by the obvious convenience factor for its users, combined with low costs and accessibility. Now, the potential of apps is being applied for treatment of one of the most severe mental conditions, affecting millions of women and many men worldwide: eating disorders such as bulimia, anorexia and binge eating.

The new wave of mobile resources for medical practice is seeing a huge growth, and sick patients have now become the first target market for publishers of apps in the health and fitness sector.

Charles Lowe, the president of the telemedicine and e-health section of the Royal Society of Medicine, believes that in just about three years many people could simply be prescribed an app when they go to the doctor.

“You can diagnose people with an app. You can treat people with an app too”, he said.

There are apps to record insulin levels, to adjust dosage of drugs or check symptoms of certain conditions. Cancer patients can receive emergency assistance via CERT (Cancer Emergency Response Tool), and tools like CF MedCare, for cystic fibrosis, help with the management of complex medication regimens.

Lowe suggested that another important use for apps would be in treatment of mental health conditions: "Apps are particularly appropriate for mental health. There is very solid evidence that apps for cognitive behavioural therapy really make a difference to people’s lives and help alleviate the effect of mental disorders ", he added.

The principles of cognitive behavioural therapy – where the therapist aims at modifying negative thoughts and behaviours through practical solutions – easily translate into digital platforms and they have been incorporated in most mental health mobile resources.

Advancing upon the few available apps providing information and academic references on eating disorders, Recovery Record and Rise Up + Recover – both founded by women operating out of the medical mainstream, one of whom suffered from an eating disorder herself – have led the way in treatment for anorexia, bulimia and overeating.

"Apps are particularly appropriate for mental health."

They have been developed as convenient alternatives to paper-based self-monitoring exercises, whereby the patient logs their food intake and makes notes of their related thoughts, feelings and urges about food.

Self-monitoring helps patients to think about triggers, based on foods and emotions, explained Kate Scruby, a London-based counselling psychologist with experience both in the NHS and private practice.

“In some other therapies [for eating disorders], this kind of apps could still be seen as patients not letting go of control, but if someone is using CBT and thinking about practicing from that angle, then it is fine."

Increasing awareness of eating patterns, compensatory behaviours (such as purging or excessive exercising) and effective coping skills, self-monitoring has a long history within this therapeutic approach; apps are just a new way of doing it.

Lauren Muhlheim, a clinical psychologist and eating disorder specialist based in Los Angeles said: “Keeping of food records is something I have asked and expected patients to do since I started working with clients with bulimia in 1994. Many prefer the app, because carrying around a food diary or monitoring sheets is more inconvenient”.

Self-monitoring also gives patients a sense of accountability and accomplishment, added Marcia Herrin, nutritionist and founder of the Eating Disorders programme at Dartmouth College, the Ivy League university: “It helps patients feel supported. In sessions, reviewing self-monitoring records can lead to insights that wouldn’t come up otherwise.”

In fact, being able to share accurate records with their treatment team, patients receive more effective support, while clinicians supervise and track progress.

Self-monitoring used to be done on paper sheets or diaries. Pic: Startup Stock/thestocks.im under Creative Commons.

Recovery Record

Free
Available for Iphone and Ipad

After seeing her best friend, who struggled with bulimia for over ten years, failing to complete long and tedious paper works assigned to her by a therapist, Australian clinical psychologist and researcher Jenna Tregarthen conceived the idea of an app to simplify food diaries, logs of feelings and any eating disorder behaviour (restricting, bingeing, purging or over-exercising).

Jenna Tregarthen, founder of Recovery Record.

The project landed her a place at the Stanford Summer Entrepreneurship Program in California, where Tregarthen worked together with a team of engineers, psychologists, psychiatrists and mobile apps developers to create Recovery Record.

The app does not represent a replacement for therapy, but it helps patients to stay committed to the treatment routine, expediting logs and offering coping skills ideas and motivational rewards such as free songs from iTunes.

A version of the app for clinicians was released later on, allowing them to provide direct support to clients in between sessions.

Talking to Australian news, Tregarthen explained: “These girls have critical moments where they have a really extreme urge to binge or purge. We are catching them in that very moment and doing therapy on the spot".

Tweets by @RecovRec

Rise Up + Recover

Free
Available for Iphone and Ipad

American oceanographer Jessica Raymond was inspired by her own recovery process to create Rise Up + Recover: while being treated for an eating disorder during college, she was assigned “extremely healing” daily meal logs and emotional state diaries.

Jessica Raymond, founder of Rise Up + Recover.

Despite this helpful practice, communication with her therapist became frustrating, as she remembered: “I spent most time in sessions reviewing my week [logs] and we wouldn’t get to the important therapeutic work until the last 15 minutes.”

Seven years later and recovered, Raymond used her experience to help others: fresh out of a Masters in Geophysics, she learned web design and contracted a developer for a self-monitoring app connecting patients to their treatment team.

“Mobile phones travel with us everywhere. They are perfect to privately capture our emotions, thoughts, and behaviours as they happen. The ability to easily share all this information with one's treatment team is a great way to stay accountable”, she explained.

Rise Up is only a supplement to recovery, as Raymond insisted: “People who believe that downloading and using an app will help them recover are being limited. They need to see a therapist and nutritionist and use the app with them.”

Tweets by @riseupapp

Stories from an App

Madelyn started binge eating and restrincting as a child. Pic: Pedro Ribeiro Simoes/Flickr under Creative Commons.

Sixteen years trapped in the lies of an eating disorder

Madelyn*, 33, Erie, Pennsylvania, USA

Madelyn has had an eating disorder for sixteen years. It became "a big problem" at the age of 17, but binge eating behaviours started as young as 8 and she was already restricting at 12. She has been diagnosed with bipolar, post-traumatic disorder syndrome and EDNOS (Eating Disorders Not Otherwise Specified) with bulimic tendencies.

Treatment History

Cognitive Behavioural Therapy; Eye Movement Desensitisation & Reprocessing; Medications

Using the App

Self-monitoring has helped Madelyn focusing on her eating patterns, understanding how they are connected to her feelings and triggered by stressful situations. Using an app has also offered her instant support at critical times: “The coping tools are useful because when in the throws of disordered eating it is hard to determine if the eating disorder “voice” is telling you the truth (‘you’re fat, ugly, you only need 80 calories a day, you need to purge that’). Especially if you cannot access a friend, therapist or dietician to process those thoughts.”

Apps alone are not enough of a commitment towards recovery. They help patients stay motivated, especially if they have already made a lot of behavioural progress through therapies, Madelyn said, but she also admitted: "The eating disorder voice is strong. If it wasn't, people wouldn't die from it. It can easily convince you to ignore the app or delete it completely." Reporting to a professional makes users feel more accountable. Madelyn said: "It's really beneficial to have someone in your life that knows you use this tool and checks in with you. It provides a sense of obligation. I need that if I'm ever going to fully recover."

"The eating disorder voice is strong. If it wasn't, people wouldn't die from it."

Tracey is a compulsive overeater and has been struggling with her weight most of her life. Pic: "Detecto" by hjl/Flickr under Creative Commons.

Taking back control over the struggle of a lifetime

Tracey*, 50, Toronto, Canada

Tracey is a compulsive eater and a binge eater. She has been struggling with weight gain since the age of 11. She was never clinically diagnosed, and although not identifying as bulimic or anorexic, she has admitted to using laxatives and restricting in the past. She has been fighting compulsive overeating through a 12-step programme since 2010.

Treatment History

Twelve-step programme for compulsive overeaters

Using the App

Tracey was first attracted to the meal logging function of the self-monitoring app, which has proven helpful and easy to use: "To be able to look back and see how I was feeling, who I was with, what I was doing at the time of the meal is very insightful", she said. The app has also helped her to spot and correct potential negative behaviours and activities, as she explained: "I use the check-in/check list feature to record the daily actions I need to take to keep on track towards recovery. It helps to keep me accountable."

Tracey insisted on the importance of using digital resources in conjunction with other forms of treatment, to maximise progress. She said apps can be useful to people who have not been diagnosed yet or are waiting to receive professional help, but she also added: "[An app] would be so much more effective if used with guidance from dieticians, mental health professionals, peer support and whatever methods will help to cope with this disease." Mobile resources offer additional help, but they should not be the only source of care. As Tracey put it: "They are a great practical tool within a recovery tool box".

"I feel that it is a great tool, within a recovery tool box"

Kristin has entered treatment twice, and she is now on her way towards recovery. Pic: "A Nice Move" by MTSOfan/Flickr under Creative Commons.

Bullied into an eating disorder, but finding the way out

Kristin*, 27, Seattle, Washington, USA

Kristin started worrying about her weight in elementary school and she was bullied throughout her teenage years, until she developed an eating disorder in 2008. At the time, her complex symptoms did not fit into the strict diagnostic criteria for anorexia or bulimia (in the US, those criteria were updated in 2013), and she was diagnosed as EDNOS (Eating Disorders Not Otherwise Specified) with behaviours of purging, over-exercise, and restricting. She entered treatment twice, and is now on her way towards recovery.

Treatment History

Cognitive Behavioural Therapy; Dialectal Behaviour Therapy; Acceptance & Commitment Therapy

Using the App

Kristin has found the use of apps very effective, as they easily allow her to track and share records of meals and moods with her treatment team, especially with her dietician. One of the most convenient aspects seemed to be discretion of use: "Apps are so helpful! They are at your fingertips whenever. Instead of having to struggle with pieces of paper, they are on your phone and decently discreet." She believes they can become an important resource, especially for young people, who are keener on mobile technology.

Despite fully realising that apps are best used under the guidance of clinicians, Kristin admitted they can become an unintentional standalone resource for people who cannot afford therapy, or they can offer sufficient support to those who are already recovered. She said: "All apps are best when used in conjunction with therapy. However, if you are recovered or mostly done with therapy, then it could be a standalone. Or it could be that, if you did not have the funds for therapies."

*Some of the names have been changed.

"It could be a standalone if you did not have the funds for therapies"

Apps are ever present and, at times, they can reinforce obsessive thoughts about food. Pic: Startup Stock/ thestocks.im under Creative Commons.

Obsession on the Go?

Self-monitoring apps present some obvious advantages: they are easy and discreet to use, and offer instant response.
While they can be helpful for most patients though, in some cases they reinforce obsessive thoughts and behaviours.
As psychologist Kate Scruby explained: "Some people can track too much. It becomes something to control, like there is a right and a wrong answer. It can be tricky". She has actually been working with some patients on not using monitoring apps and helping them to trust their own feelings about hunger and related emotions.

She said: "Usually, if patients come to me and they have been using them [the apps], I need to get them off. On the contrary, with people that have not been tracking information, it is about making them record things to raise awareness".

Different Use for Different Disorders

Self-monitoring practice has to be tailored to patients' needs, fitting within their personal struggle.

Nutritional therapist Marcia Herrin noticed that many anorexic patients have a tendency to OCD that self-monitoring can aggravate. Kate Scruby, though, pointed out that while some patients obsessively keep records of what they ate and drank, they often lack in emotional tracking and self-monitoring can be a way of forcing them into thinking about emotions.

She explained: "It [self-monitoring] lends itself more to bulimia and binge eating, but certainly there is a part of it, the emotional part, that can be really helpful with anorexia too."

Calorie counting is intended for weight loss and would be problematic for patients with an eating disorder. Pic: Jacob Edward / Flickr under Creative Commons.

No Counting

Designed specifically for patients with eating disorders, Recovery Record and Rise Up + Recover do not register calories of food intake, unlike most tracking apps. In effect, they aim at reducing patients’ unhealthy obsessions over numbers, measures and strictly regimented eating habits.

Eating disorder specialist Lauren Muhlheim explained that calorie-counting apps are designed for weight loss and would be very problematic for patients with eating disorders, as they increase a focus on numbers.

Marissa Carrarini, a nutritional therapist from a London outpatient clinic for eating disorders, added that calorie counting is very "harmful and unhelpful" as it fails to acknowledge what our bodies really need to eat.
Apps in general avoid "looking inwards", and promote an unnatural approach to food: "People with eating disorders like rules and calculating. Apps fail to teach that one needs to listen to the body and accept that every day is different", Carrarini said.

Personal Information and Data Privacy

Data security was identified as the biggest "potential show-stopper" for the mobile health market in a recent industry research, as dealing with very sensitive information -- personal health records -- obviously raises legitimate concerns.

While Rise Up + Recover specifies that all data inputted in the app is only stored locally on the user's device (whether a smartphone or a tablet), with Recovery Record policies are more complicated as the service allows an advanced interaction between patients and clinicians, resulting in a complex exchange of information.

Juan Pablo Luchetti, a director at Mubaloo, a mobile experts' firm who has previously worked with the NHS on apps for mental health, said that it is important to use recommended apps from trusted sources and to download them only through official stores, as they guarantee a higher level of security. He advised: "If you download an app and it's not from a reputable company and it starts asking for lots of information, then delete it".

From email therapy to interactive apps, technology can provide flexible services to improve care or reach patients who would not otherwise have access to it, but some reservations remain.

Clinical psychologist Scruby expressed worry: “I would be scared of people just using an app on their own”, as professional guidance is needed to review progress, to identify critical aspects and establish a general treatment plan.

Eating disorders are severe conditions that require face-to-face health assessments, but the right combination of technology and human interaction could be the key to more effective treatment.

Charles Lowe, from the Royal Society of Medicine, explained: "In the area of mental health, a combination of app and face-to-face sessions would probably work best. That way the clinician would be able to focus the app much more effectively."

"I would be scared of people just using an app on their own."

In the UK alone, at least 1.6 million people are suffering from an eating disorder and data from the Health and Social Care Information Centre reported that hospitalisations have increased by 8% in just one year, between 2012 and 2013; public resources struggle to cope.

Frances Mitchell, a helpline manager from B-eat, the UK biggest charity for eating disorders, reported an alarming scenario: "The demand for treatment is not being adequately met through the NHS. When sufferers are not offered treatment or have to wait, the emotional strain can lead to mental health issues within family members, who can also struggle to access support."

She identified the most common problems to be long waiting times, the distant location of facilities or patients being refused treatment for looking "physically well", a fact that completely disregards the deep emotional and psychological strain of mental illness.

About the potential of self-monitoring apps as treatment resources though, Mitchell didn't sound too excited: "People can find it helpful to keep a mood diary, but it is possible to do it without an app too".

Mitchell's scepticism towards mobile health is not an isolated case and perhaps it reflects a widespread attitude among clinicians in the UK.

Over a year ago the NHS launched a library of applications approved as clinically safe and complying to data protection laws. The promising initiative has since grown to count over 200 resources, but doctors and medical staff remain wary and adoption of health apps is, in fact, very low.

Charles Lowe believes that this is partly due to some sort of "natural medical conservatism" combined with safety concerns. "There are unsafe apps around, and doctors are understandably challenged".

And not all apps do the job they are supposed to. Lowe cited the case of an app that claimed to measure blood pressure by being put close to the heart. "It is absolutely rubbish! And still, it was one of the top ten grossing apps in the Apple store".

"Doctors think apps can't be trusted."

Incidents like that certainly do not help apps building a reputation, and lack of regulations allows thousands of unsafe applications to be put on the market and distributed worldwide: "There is not good policing. Doctors think they [apps] can't be trusted", Lowe said.

He is currently working with the National Institute for Health and Care Excellence (NICE is a public body responsible for developing guidance and quality standards in social care) to start an evaluation of apps' cost-effectiveness and make it easier to identify and recommend safe resources.

"We need to create more of a trust environment", he urged.

Lowe explained that only NICE-covered products can be easily prescribed through the NHS, so an official ruling over apps could promote digital health across all levels of the public system, from hospitals to family doctors, broadening access to care for patients and allowing a more cost-effective approach to treatment.

In fact, remote monitoring could prevent cases of non-compliance and shorten the duration of hospitalisations, while mobile diagnostic has the potential to reduce the number of clinical examinations to be performed.

Of course, data and algorithms will never substitute doctors in flesh, but with ever-shrinking public funding and increasing demand for treatment, it is very possible that mobile technology will grow to play a bigger role.

"We need to create more of a trust environment."

Cristiana Bedei is a digital journalism postgraduate student at Goldsmiths, University of London (UK).

She mostly writes about visual culture and gender issues and has been published on The Huffington Post, Feminist Times, The Girls Are, D'Ars Magazine and more.

Currently, she is a Student Reporter Fellow within the Women in the Media series.

CREDITS:

Header image: Marco Derksen/Flicker under Creative Commons.
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Background image one: 'Technology' by abdullah.khan2012/Flickr under Creative Commons.
Background image two: 'Anorexia' by Benjamin Watson/Flickr under Creative Commons.

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