When the phrase “There’s an app for that” was officially trademarked in 2010, few likely presumed that it would apply to the treatment of eating disorders. On the contrary, phone applications (apps) like Instagram and Pinterest were thought to exacerbate eating disorder symptoms by making it easier to search and share “Thinspiration” for weight loss. Yet, there are now dozens of apps that are being used to augment more traditional in-person eating disorder treatments like cognitive behavioral therapy (CBT). In fact, apps for eating disorder treatment have grown in popularity so much over the last decade that large-scale empirical reviews of the quality of these apps have found their way into top-tier eating disorder journals. And, in the past three years, the National Eating Disorders Association’s Feeding Hope Fund sponsored two projects proposing to develop and test an app to aid in eating disorder recovery. What was once deemed a fad is now an invaluable addition to many treatment protocols.
Why Use an App?
CBT for eating disorders typically consists of one hour-long session per week. This means there are 167 hours (and over 20 meals) in the week where the patient must put into practice the insight gained and homework prescribed from the previous CBT session. What better way to help patients through the potential challenges of the week than with a tool they literally have in their back pocket? Approximately 77% of Americans own a smartphone, a statistic that is rising annually. While the peak onset age for eating disorders is late adolescence and early adulthood, it happens that about 92% of this demographic (18 to 29 year-olds) owns a smartphone. Whereas smartphones were initially considered a luxury device, available financially to just a select few, current data show that, among households with an annual income of $30,000 or less, 64% of these individuals own a smartphone. Because smartphones, and therefore the ability to download apps, are widely accessible, apps are becoming an increasingly valuable tool in eating disorder treatment.
A critical component of CBT for eating disorders is engaging in regular eating. Regular eating typically entails eating three meals and three snacks at evenly spaced time intervals throughout the day (i.e. no more than 3-4 hours apart). Patients are instructed to monitor their regular eating each day using handwritten diary logs. Because these logs can be cumbersome to carry, it then becomes easy for patients to forget to log their week. Many work admirably to complete them from memory in the waiting room prior to their session (leaving clinicians perplexed as to why the logs are all filled out in the same pen!). With apps, patients can record their food intake without having to carry around paper logs. Out with friends or in public? Logging is as inconspicuous as checking email or sending a quick text! Short on time? Most apps have a feature where a simple picture of the plate will suffice as a log. And, because logs from previous weeks can more easily be saved electronically on the app (compared to saving piles of paper logs), patients can look back on previous weeks to reflect on their progress.
In addition to reminding the patient to eat regularly throughout the day, the food logs in these apps also serve as data points for the patient to notice patterns between eating disorder behaviors and emotions related to external events. Most apps have features that allow patients to describe thoughts and feelings, in addition to food intake, throughout the day. Did a fight with a significant other precede a binge one evening? Did feelings of guilt and shame about the binge prompt an episode of compensatory exercise? Apps allow for accurate “data collection” for predicting future patterns because patients can more easily record their food, thoughts, and emotions in real time. This is extremely valuable as it allows the clinician and patient to work together to anticipate potential triggers for problematic behaviors and plan strategic alternatives, critical components of treatment.
Perhaps the most attractive feature is that apps are equally as helpful for clinicians as they are for patients. By granting clinicians a window into the patient’s week, clinicians can more accurately assess whether their patient has eaten regularly, completed relevant homework, or whether an external event prompted a disordered behavior. This can be crucial in helping the clinician adequately prepare for the patient’s next in-person session and in allowing the clinician the opportunity to identify and provide feedback to the patient via the app. With paper logs, clinicians are not able to provide feedback between in-person sessions. Therefore, with an app, the patient might have the opportunity to get back on track after a brief lapse, before a more serious relapse occurs.
Finding an App That’s Right for You
For readers who might be app-shopping to bolster their recovery, a word of caution: some apps market themselves as recovery tools but only track calories. This can be triggering for individuals trying to steer clear of calorie counting and can even prompt individuals to skip meals or snacks, which is the opposite of engaging in regular eating! Instead, be sure to choose an app that allows for tracking thoughts and emotions in addition to meals. If you are unclear if an app is recovery-oriented, ask a member of your treatment team. There are also a variety of apps that are specifically designed for assessment. Users can take questionnaires that have been validated to detect clinically relevant eating disorder symptoms. If you are unsure if you should seek treatment, these apps might be a good place to start, though, ultimately, they should not substitute for an assessment by an experienced eating disorder professional.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Fairburn, C. G. and Rothwell, E. R. (2015), Apps and eating disorders: A systematic clinical appraisal. Int. J. Eat. Disord., 48(7), 1038–1046. doi:10.1002/eat.22398
Juarascio A. S., Manasse S. M., Goldstein S. P., Forman E. M., and Butryn M. L. (2014). Review of smartphone applications for the treatment of eating disorders, Eur. Eat. Disorders Rev., 23, 1–11. doi: 10.1002/erv.2327
Smith, A. (2017). Record shares of Americans now own smartphones, have home broadband. Pew Research Center.
About the Authors:
Kathryn Coniglio is a clinical psychology doctoral student at Rutgers, The State University of New Jersey. Under the mentorship of Dr. Edward Selby, her research seeks to better understand the role of both negative and positive emotion in promoting a variety of eating disorder behaviors, including excessive exercise. Ms. Coniglio is also a member of the Academy for Eating Disorders, and serves as the co-chair for the Early Career Special Interest Group.
Christopher Mancuso is a clinical research coordinator in the Neuroendocrine Unit at Massachusetts General Hospital, where he serves as the primary coordinator for the MGH Brain Study, examining homeostatic and hedonic reward in adolescents and young adults with anorexia nervosa. He has also previously worked as a residential counselor in the Klarman Eating Disorders Center at McLean Hospital.