FINDING BALANCEBy Megan Faletra and Stephanie Simms

Overview of Finding Balance App● Works with the pre-existing FitBit and

Weight Watchers Applications with the goal of helping obsessive exercisers (with eating disorders) find balance in their intake and exercise.

● Works by establishing a support network of care providers who can manage and track the individual's progress as well as provide feedback and 24/7 online support. This support network will be notified when the individual is falling off track, and can reach out to them for support.

● Allows the user to still track their behavior, which is something they enjoy, however the app disables all “harmful” functions such as calorie counting, and extreme “step goals”, and replaces them with better tools for balancing energy intake and activity.

Target Population & Health ProblemTarget Population

• Anorexia Nervosa and Bulimia Nervosa Patients with Compulsive Over-Exercising, are patients who suffer from Anorexia Nervosa or Bulimia Nervosa, and use exercising as a means of purging and controlling weight and body shape.

• Female College Athletes

Population Access

• It is projected that 85-95% of individuals with an eating disorder have access to a gym, or fitness center

Description of Health Problem

• In the case of patients who suffer from bulimia nervosa with compulsive over-exercising, these individuals are using exercising as a means of purging and a way to control their body shape and weight. 55% of all patients with bulimia nervosa over-exercise.

• In the case of patients who suffer from anorexia nervosa with compulsive over-exercising, these individuals use exercising as a means of restricting, and maintaining a low-body weight. 90% of all patients with anorexia nervosa over-exercise.

Persona (Molly)Description

• Molly is 20 years old and runs for her college cross-country team.

• Molly is 5’5” and weighs 110 pounds, she would like to weigh 100 pounds or just under 100 pounds.

• Molly is an honors student and one of the top runners on her cross-country team, she also pays for her school and has a part-time job.

Molly’s Eating Habits

• Molly eats roughly 1000 calories per day and is 5’5”

• Molly restricts her diet from a set of designated “bad foods”, and ultimately binges about 1-3 times per week.

Molly’s Exercise Habits

• Molly exercises 2-3 times per day

Molly’s Triggers

• Exams, cross-country meets, and work (paying for school)

• Social Gatherings, and holidays

Molly’s Current Energy Balance

• Negative energy balance resulting in weight loss

• Too much exercise without enough food

Pilot Design• Three colleges will be targeted for the initial pilot

of the Finding Balance App for the treatment and management of obsessive exercising in anorexia nervosa and bulimia nervosa college student athletes

• 20 to 30 college athletes will be recruited from a variety of collegiate sports (gymnastics, swimming, running, tennis, etc.)

• Students will be recruited from the college counseling center and will be recommended to the program by their current counselor/therapist who has deemed that the program would be safe and helpful for the student.

• At this point students will not be allowed to begin the pilot program without the explicit permission of their therapist.

• Students will need to currently be receiving counseling and will have to agree to allow their coach, team trainer, a nutritionist, and primary care physician to access their food and fitness behavior (through the app). These people will form the student’s “support team”

• If the student is under 18 years of age the student’s parents will also need to sign-off on the pilot program

Duration• The pilot will take place over the

course of a three-month time period.

• In order to determine if positive changes are made in this population we will need a minimum of three months to determine if the app is capable of supporting healthy behavior change.

• Because disordered eating recovery can require years of therapeutic treatment we have determined three months to be an adequate baseline for determining if moderate healthy behavior change is possible through the additional support of the Finding Balance application

Management• The management of the Finding Balance Pilot Study will be managed by a

team of qualified professionals

• Project Manager: Works at the highest level to ensure the application is used as planned and answers logistical questions about the application or the pilot study.

• Project Coordinator: Works with the colleges or universities to recruit the student athletes and collects necessary data related to the application.

• Designer: Develops the application; updates the code when necessary and answers technical questions.

• Psychology Consultant: Provides expertise related to the psychological aspects of the application.

• Nutrition Consultant: Provides expertise related to the nutrition/food intake aspects of the application.

• Fitness Consultant: Provides expertise related to the exercise aspects of the application.

• General Medicine Consultant: Provides expertise related to any general health related questions.

Marketing and Recruitment• Due to the sensitive nature of the health problem of interest, marketing

and recruitment will need to be conducted in a very thoughtful manner.

• The best places to advertise the program has been determined to be in “safe” areas where the students already frequent.

• College health center, counseling center, coaches offices, trainers offices

• Primarily for the purpose of the pilot study college therapists will be used to recruit student athletes.

• Additionally, if a college therapist is aware that a student athlete is in therapy with an external therapist, the student can be recruited through the external therapist as well

Budget/FundingFunding

• Initially we will look to college and university campuses for the budgeting of the application. Ideally we would like to integrate it into the counseling support services offered on college campuses.

• Campuses which have statistically high prevalences of eating disorders will be targeted first.

• Additionally, we will apply for funding through the American Academy of Dietetics as well as the American Medical Association, and the National Eating Disorders Association

• National grants focused on addressing mental health issues, specifically those pertaining to eating disorders will also be targeted for funding support.

Budget • $50,000 ($10,000 design, $10,000

coding, $5,000 marketing, $25,000 consulting)

Risks• It will be imperative that our application

not enable the individual to further over exercise.

• The confidentiality of the individual will be important to gain trust of the support team and of the management of the application. This is why the use of alreadycommon technology such as the wearable FitBit will be used so the student does not stand out among their peers.

• This is somewhat of a short term solution so the college should continue to treat the student for their eating disorder beyond the pilot of Finding Balance.

Limitations• Since we are dealing with a very

sensitive issue (anorexia nervosa, and bulimia nervosa eating disorders), there will be no way for us to gather a random sample or diverse sample in our pilot.

• Initially because we want to ensure that the application is safe and successful in a group of students with a well defined support group, we will not be able to address students who may not have an already present support group, therefore we are aware that we will be missing a vulnerable portion of this population.

• The application is meant to be gender-neutral in its design, and library of foods and activities, however because far more females than males suffer from these disorder it is anticipated the females may respond more positively to this application.

Projected Outcomes• It is anticipated that some of the

students will not be capable of completing the study for various health concerns, or do to lack of motivation to change or self efficacy to continue their current treatment.

• We anticipate that student athletes who complete the entire pilot study will have made some small measures of behavior change, and will be in a more stable, and will have become accustomed and interested in using the application to support their recovery.

• Specifically, we expect to see a progression towards less of an energy deficit among student athletes in the study, and slower weight loss, weight stabilization, or weight gain depending on the particular student athlete.

Evidence Based Guidelines• “Preliminary evidence for the efficacy of mobile interventions” in treating

patients with eating disorders- specifically Bulimia Nervosa (1) • Mobile health tools “may enhance treatment for eating disorders” (2)

• “Overall, existing eating disorder intervention apps contained minimal evidence-based practices and failed to incorporate smartphone capabilities. For smartphone apps to be a feasible and effective ED treatment modality, it may be useful for creators to begin taking utilizing the abilities that set smartphones apart from in-person treatment while incorporating EBPs. Before mobile health tools are incorporated into treatments for EDs, it is necessary that the feasibility, acceptability, and efficacy be evaluated.” (2)

• Systematic Review revealed that there were 39 applications primarily designed for those with eating disorders and five applications designed for professionals who treat those with eating disorders (3)

• One app allowed the sharing of information between a clinician and a patient

• There is a need for a self-monitoring feature• Could deliver a personalized intervention

Theoretical Framework • In order to address disordered

eating and excessive exercising it is critical in the first stage of recovery to address a person’s self-efficacy to change, and make healthier choices.

• In the case of Finding Balance, the application is being designed to help the student athlete make healthier choices, and become more motivated to continue working towards recovery.

• Additionally, the theory of planned behavior and the stages of change model were used as the backbone for determining how to aid a person in moving from precontemplation, or contemplation into an actual change in their behavior.

• It is also important to understand how relapse and maintenance play into eating disorder recovery, and how the app can support these various stages.

Next Steps• We envision the next steps of this

project to be an expansion across college campuses and a roll-out of the application to all college campus counseling centers.

• We also will conduct an additional pilot study with students who do not have a current support group already in place, and will allow for students to enroll in the study. These students will be assigned a support team who will use the application to monitor their current health status.

• If Finding Balance is successful on college campuses, it is possible that the application will be made public and capable of being used by non-student athletes as well. This will require recruitment of support team professionals willing to participate in this form of supplemental treatment nationwide.

References1. Schlegl, S., Bürger, C., Schmidt, L., Herbst, N., & Voderholzer, U. (2015). The

Potential of Technology-Based Psychological Interventions for Anorexia and Bulimia Nervosa: A Systematic Review and Recommendations for Future Research. Journal of medical Internet research, 17(3).

2. Fairburn, C. G., & Rothwell, E. R. (2015). Apps and eating disorders: A systematic clinical appraisal. International Journal of Eating Disorders.

3. Juarascio, A. S., Manasse, S. M., Goldstein, S. P., Forman, E. M., & Butryn, M. L. (2015). Review of smartphone applications for the treatment of eating disorders. European Eating Disorders Review, 23(1), 1-11.