Smartphone Apps for Eating Disorders Recovery

By Emily Presseller and Kelsey E. Clark

Traditional in-person treatment is inaccessible for many of the thousands of people with eating disorders.¹ This may be due to any number of barriers, including lack of specialized treatment providers, limited treatment options, high cost, insurance restrictions, stigma, and health care disparities.^2,3 The current COVID-19 coronavirus pandemic adds yet another potential barrier.^4-7 Many individuals, families/caregivers, and treatment providers are being forced to transition to remote care. Furthermore, early evidence suggests that the pandemic is contributing to a worsening of mental health symptoms, including stress, anxiety, and

depression.^8,9 Early research has also found evidence of worsening eating disorder symptoms, including dietary restriction, binge eating, excessive exercise, and food-related fears, as well as risk for relapse among people with eating disorders.^10,11 Those with eating disorders may be particularly affected by pandemic-related stressors, such as media coverage of food shortages, articles about curbing “emotional eating” and the “Quarantine 15,” lack of structure in eating and sleep routines, disruption of daily activities and physical activity, reduced social support, heightened negative emotions, and increased practical demands of families/caregivers.^4,5,7,10,12

With COVID-19 disrupting treatment delivery and increasing need, interest in telehealth services has skyrocketed.^4,13-15 Telehealth refers to services delivered using electronic information and communication technologies.¹⁶ It is an umbrella term that includes health care delivered via phone, video, the internet, or smartphone applications (apps), as well as online record-keeping and billing tools.¹⁶ In recent years, there has been an explosion of new mental health smartphone apps. As of 2019, more than 10,000 mental health apps were available, with the rate of new releases growing.¹⁷ Goals of these smartphone apps include making treatment more interactive and collaborative, improving adherence to treatment outside of the therapy office, offering more opportunities to practice treatment skills, and giving treatment providers more information upon which to base treatment decisions.¹⁸ In this article, we’ll focus on the use of smartphone apps for eating disorder recovery. First, we will share a broad overview of the benefits and key features of eating disorder recovery apps. Next, we will discuss challenges with these apps and things to consider when choosing one. Finally, we will highlight some of the most popular eating disorder recovery apps.

5 Benefits of Apps for Eating Disorder Recovery

1. Wide availability. Smartphone apps are available all around the world. As of 2019, more than 81 percent of American adults owned smartphone devices.¹⁹ Zooming out, as of 2020, there are 3.5 billion smartphone users worldwide.²⁰ Many people, including individuals with eating disorders, have positive, optimistic attitudes toward using telehealth apps and already plan to use them.²⁶
2. Convenience. Most people keep their smartphones within arm’s reach.²¹ The convenience of apps relative to traditional treatment is clear: Apps don’t require appointments, travel, child care, or other arrangements. You can use an app almost anywhere, anytime, and in daily life immediately before/after eating disorder behaviors.²¹
3. Ability to reach underserved populations. Apps are one potential solution to make treatment accessible to systemically underserved groups.² Apps for eating disorders provide opportunities to overcome barriers to seeking treatment in individuals with diverse socioeconomic or racial/ethnic backgrounds, and with genders other than female.²⁸ Many apps are cost-effective, if not free.²¹ Apps may also allow people who feel ambivalent about treatment to ease into it,²⁹ as they are low-intensity and self-paced.³⁰ Apps enable anonymity²¹ and may reduce feelings of shame or stigma linked to seeking help.^26,29
4. Potential to boost traditional in-person treatment. Mental health apps are not always intended to replace professional clinical treatment. However, they can be useful for individuals who cannot receive standard care.³⁰ Blending in-person with app-based approaches may offer additional benefits.³¹ Apps offer extra support between outpatient treatment sessions and when stepping down from higher levels of care. Much of the “work” in treatment happens outside of the therapy office, without the therapist present. For instance, many of the behavior changes required for eating disorder recovery include doing things differently when eating meals and snacks, grocery shopping, exercising, using compensatory behaviors, and when experiencing urges. Smartphone apps may help individuals practice making changes and cope effectively as they go about daily life.
5. Some established research support. Making research-supported treatment broadly accessible is a key priority in the mental health field.³² Existing apps vary greatly, but a few meta-analytic studies (which combine data from many scientific studies to summarize the overall findings) have found support for some existing apps. One meta-analytic study found mental health treatment apps to generally be effective relative to control treatment conditions.³⁰ Another found that users can learn acceptance, mindfulness, and self-compassion skills from treatment apps.³³ Single studies show that some eating disorder recovery apps are feasible to use and believed to be helpful, and that patients and clinicians are willing to use them.^34,35 Eating disorder recovery apps can reduce eating disorder symptoms, reduce body dissatisfaction, and improve body satisfaction and body image, and these effects can continue over time.^36-40

5 Key App Features for Eating Disorder Recovery

1. Self-monitoring. Several app features may help with streamlining essential aspects of eating disorder treatment. For instance, self-monitoring, or recording all meals, snacks, and disordered eating behaviors (e.g., binge eating, compensatory behaviors) is an important part of many research-supported treatments.^18,41 This self-monitoring can be completed within an app, increasing convenience, accessibility, and privacy compared with using paper records.⁴² Some apps make self-monitoring easier by logging foods with photos or bar code scanning. Some apps also allow self-monitoring records to be downloaded or printed for clinicians.^18,43 Having a clinician view records in real time may provide helpful accountability for users stepping down from higher levels of care. App records can enable routine monitoring of progress throughout treatment, which has been found to improve outcomes.⁴⁴ Apps can include a journaling or comments section, allowing the user to share experiences with their treatment provider and note topics to discuss in therapy.
2. Interactivity. Eating disorder recovery apps often include interactive elements. Users can collaborate with clinicians, interact with peers, connect to sources of help, and get encouragement via point scoring or rewards. When used in addition to in-person or telehealth treatment, apps can facilitate communication between the patient and provider.⁴² One study found that 51 percent of apps targeting common mental health concerns use various features found in games (e.g., points, rewards, competition with others) to encourage users.⁴⁵
3. Potential to intervene in-the-moment. Smartphone apps can use push notification reminders to complete self-monitoring records and other homework. This supports more consistent, accurate tracking and provides chances to practice skills learned in therapy.^18,41 Many apps include curated educational resources about symptoms, coping skills, and treatment strategies.^18,42 This information is shared in the form of videos, text, or illustrations, and is designed to be easy to find and understand.⁴² Content can come from established, research-based treatments like cognitive behavioral therapy or acceptance-based treatments.¹⁸ What’s more, apps may be able to deliver real-time suggestions of specific skills to use in the moment, based on what the user is struggling with.⁴⁶ For instance, an app could provide suggestions in response to changes in eating patterns that increase the likelihood of disordered eating (e.g., remind the patient to eat at regular intervals to help prevent binge eating). When the user records feeling a negative emotion or an urge to engage in disordered eating behaviors, the app may suggest a coping strategy they can use to help manage their emotions or urges in a healthy way. A user can get help from an app right away, rather than waiting until their next therapy session.
4. Potential to provide more information for treatment planning. Treatment apps can be integrated with other apps, such as a fitness-tracking app to monitor physical activity. Using wearable devices, apps can collect data passively, such as measuring glucose levels, time passed since last meal, steps taken, or geographic location.⁴¹ An app can also deliver short surveys periodically throughout the day to collect data about the user’s experiences.⁴¹ App users and treatment providers both benefit from better understanding patterns of internal (e.g., thoughts, feelings) and external (e.g., situations) experiences that keep symptoms going.^41,47 Apps can also summarize data in ways that make it easy for users to understand, like using graphs, describing overall trends, and making predictions.^41,47
5. Potential for personalization. There is growing interest in personalizing apps to an individual’s specific symptoms and situation to improve app use and treatment outcomes.^28,48 Users differ in their specific treatment needs, so differing options should be available within apps. Research suggests that a personalized app tailored to a specific user may be more effective than a generic app.⁴⁸ Examples of individualizable features include: tracking various behaviors, turning off certain features, providing graphs and data summaries, sending unique messages, supplying a variety of skills/strategies, and making a variety of material available.

5 Challenges of Apps for Eating Disorder Recovery

1. Limited or lack of research support. While eating disorder recovery apps show great promise, they have yet to be fully researched. Overall, little is known about how safe, practical, or effective eating disorder recovery apps are. When reviewing the available data, many researchers have concluded that the usefulness of existing apps is unclear.^29,49-52 This does not mean the apps are unsafe, impractical, or ineffective—rather, we don’t yet know enough to be able to make general conclusions. We need more studies, larger studies, and higher-quality research. Because of the way past studies were run, many questions remain unanswered.^30,33 For example, most studies have examined an app on its own, or have only compared it with a control condition in which participants received no treatment. Such studies can establish that an app is worth examining further, or that an app is “better than nothing” (i.e., more effective than no treatment at all). More research is needed that compares apps with existing treatments.

Other limitations of existing research include a high rate of participant dropout, including only participants with mild disordered eating, and not looking at how apps work in the long run.^21,30 The world of telehealth and technology moves fast; it is challenging to quickly run large, cost-effective studies.⁵³ Therefore, apps used in research studies are not necessarily commercially available right away.⁵⁴ There is also room for improvement in the variety of people involved in the app development and research process.^53,55,56 Many in the field have called for meaningful collaboration across community stakeholders (i.e., app users, experts by experience, clinicians, researchers, app developers). This is critical, as each stakeholder may have a different perspective on the quality and utility of an app. Finally, there is a lack of consensus regarding guidelines for evaluating apps.^53,57-59 While various listings of apps, comparison websites, and guiding frameworks exist, these often disagree and are challenging to keep up-to-date.

2. Risk of providing insufficient or harmful treatment. We can’t ignore ethical concerns associated with these apps.⁶⁰ One concern is that people may inaccurately view apps as a true replacement for in-person or telehealth treatment. One study found that half of users of a popular eating disorder treatment app were not currently receiving treatment, and one-third reported they hadn’t told anyone about their eating disorder.⁶¹ The widespread availability of apps can send the inaccurate message that anyone can easily manage an eating disorder with an app alone.⁵³ When a higher level of care is warranted, solely using an app is inappropriate. App users often have severe symptoms, and many have never received specialized eating disorder treatment outside the app.⁶¹ User reliance on an app that is insufficient is concerning even if the app is not directly harmful. If someone believes that they are addressing their eating disorder by using the app, but the app is actually insufficient or ineffective, then they will be delayed in starting evidence-supported treatment.⁴⁹

A clear concern is the availability of eating “recovery” apps, or related apps, that may be harmful to users.^29,52 The vast majority of treatment apps fall outside the enforcement of public health regulatory agencies, such as the U.S. Food and Drug Administration.⁶² In many countries, mental health app regulation has become a “hot potato,” with oversight being difficult to handle and passed between policy makers, industry, app distributors, and nonprofit organizations.⁶³ Because of the lack of evaluation and oversight, a notable subset of apps provide treatment that is inconsistent with evidence-based care, or that is potentially harmful. Shockingly, one study found that the top 25 most popular apps for treating anxiety did not include any content consistent with evidence-based treatment.⁶⁴ Another study found that half of the eating disorder apps examined provided potentially harmful information, such as anorexia nervosa “tips.”⁵² Some people may be inclined to use popular calorie-tracking apps, which aren’t designed for individuals with eating disorders and may be unsafe.⁶⁵ As an example, the app MyFitnessPal is widely used among people with eating disorders, and a study revealed that app users generally believed the app contributed to their eating disorder.^66,67 Many fitness/dieting apps are wildly popular; for example, MyFitnessPal has been downloaded from the Google Play Store over 50 million times.⁶⁸ This dwarfs the most popular eating disorder recovery app, Recovery Record, which has been downloaded over 100,000 times.⁶⁸ 

3. Privacy and data security concerns. Experts caution everyone to remember that the growing telehealth “digital economy” is rooted in the practice of collecting and selling users’ data.⁵³ This fact raises many ethical concerns regarding privacy, data security, and data ownership.⁶⁰ The highly personal and sensitive nature of mental health care makes these concerns all the more critical and complicated. In one study, eating disorder recovery app users acknowledged that security is important, but at the same time, they said app security features can interfere with app use (e.g., requiring too many authentication or identification steps³⁴). Unfortunately, it is often very challenging to evaluate apps. One study examined the top 36 apps for depression and smoking cessation and found that 29 transmitted data to services provided by Facebook or Google, but only 12 disclosed this accurately in privacy policies.⁶⁹
4. Barriers to access for users and treatment providers. Although smartphone apps can increase treatment access, they are still not accessible to everyone. Smartphone devices are expensive, app availability varies by operating system, apps may not be covered by health insurance, and not all individuals with eating disorders have consistent internet access or the necessary familiarity with technology to use a smartphone. Smartphone apps may not be equally accessible to individuals of different ages, income levels, locations (e.g., rural versus urban areas), literacy levels, English proficiency levels, and abilities.^70-74 Even if apps are accessible, they may not have been researched in diverse populations, or may not have been designed with every type of patient in mind.⁷⁵ For instance, many apps for eating disorders are coded traditionally feminine with regard to design elements and user interface. Exciting efforts are being made to develop mental health apps intended for diverse groups, such as those with physical disabilities,⁷⁶ and Black,⁷⁷ Indigenous,⁷⁸ and people of color (BIPOC), but more work is needed. It’s important to note that personal preferences and willingness to engage with new technology vary from one person to the next—some patients may simply prefer face-to-face treatment.²⁶ Apps can be experienced as supportive or as obstructive, depending on the person and their individual needs and circumstances, so personal choice should always be maximized.^53,79 Clinicians may be concerned that having 24/7 access to patient data via apps will increase workload or affect the working relationship with their patients. Unfortunately, little research has examined these aspects of implementing apps as part of treatment.^80,81 Differences between patients, clinicians, treatment facilities, and organizations likely have an impact on user experiences.^52,80,82
5. High rate of discontinuation. While their convenience provides many benefits, smartphone apps are just as easy to put down as they are to pick up. This may yield frequent discontinuation of use, as well as limited engagement with or effort put into use of the app. Continued user engagement and interest are major concerns for many researchers.²¹ In fact, discontinuation of app use is a general concern: Industry data indicate that almost 75 percent of health app users stop engaging with apps after only 10 uses, with 21 percent of users abandoning apps after one use.^83,84 This has led app developers and researchers to explore ways to maintain use over time, including rewards/achievements, periodic updates, “unlockable” content, frequent prompts, and clinician encouragement.^28,34

5 Considerations When Choosing an App for Eating Disorder Recovery

1. Understand the typical process of choosing an app. It is helpful to consider how most users typically select apps. Apps that are less expensive and have optional in-app purchases, age restriction, or a higher rating are downloaded more often.⁸⁵ Recommendations, popularity, name recognition, search result order, high ratings, word of mouth, and social media all are factors in how people find apps.⁸⁶ Professional recommendation and inclusion of treatment providers in app development often do not affect users’ mental health app choices.^53,85 Researchers have highlighted the importance of using eating-disorder-recovery-specific apps, noting that general food diary apps or weight-loss apps can allow users to fall back into eating disorder behaviors, even when their goal is recovery.⁸⁵ It is also notable that searching for eating disorder recovery apps typically brings up weight-loss apps in search results.^68,85 Treatment providers are encouraged to be proactive and ask patients whether they use apps, and perhaps consider whether recommending apps to patients would be beneficial.⁸⁵
2. Do your homework about privacy/security. Before choosing a smartphone app, users should assess several aspects of the app.⁸⁷ First, the user should look into the precautions taken by the app to protect user data (e.g., password protection, data encryption). Users should then investigate whether the app shares user data with third-party companies. Users can look at the app website and browse user reviews to learn about the security features and privacy policy. Despite what privacy policies say, experts have indicated that users should generally assume their data will be shared with other organizations/entities and proceed with caution.^41,69 Unfortunately, app privacy policies and security measures evolve over time, so it is often difficult for users to make a fully informed decision.⁶⁹ Foundational privacy and security features that should be prioritized include data encryption, password protection, and compliance with health information protection legislation, such as the Health Insurance Portability and Accountability Act (HIPAA).^41,88 

3. Know the limitations of existing research regarding how safe, practical, and effective apps are. Users should identify whether the app has any research support for its use in eating disorder recovery. App users and treatment providers should be aware of the potential serious concerns about the lack of knowledge regarding app use.¹⁷ Users can ask their clinician to help identify whether any research has evaluated the app. Eating disorder clinicians can also look over the app to determine whether it follows evidence-based treatment guidelines and is compatible with treatment goals. Many professionals have put out calls for standards and relevant resources to be made available to help evaluate apps, but the field has yet to reach a consensus.^17,54,57 In the meantime, it is recommended that users and providers seek out apps that translate existing evidence-based treatment approaches.¹⁷ However, using scientific descriptions or the name of an established treatment does not necessarily mean the app is truly evidence-based. For instance, just because an app description uses technical language and claims to deliver cognitive behavioral therapy, that does not mean it is aligned with actual principles of that treatment.⁸⁹
4. Consider the logistics and coordinate app use with others. Users should consider aspects of the app’s user experience.^35,90 For instance, they should evaluate the cost of the app (e.g., download cost, ongoing subscription fees) and determine whether use of the app is financially feasible. If the user is working with a treatment provider in addition to trying out a smartphone app, the user should identify whether the app facilitates communication between clinician and patient, and discuss whether their clinician has interest in using such an app. Clinician guidance and reminders when utilizing mental health apps are associated with greater efficacy.⁹¹ Therefore, the clinician should be involved in all steps of decision-making around the use of a smartphone app and should continually check in with the user around their experience of using the app. Patients, clinicians, and families/caregivers should clearly communicate with one another about how app data will be viewed and used.⁹² If a patient is working with multiple treatment providers, it is recommended that options for data sharing (e.g., integrating app data into the electronic medical record) be discussed.^92,93 With child and adolescent patients, discussions should also address parental monitoring and limits to smartphone access.⁹³
5. Remember that what works for one person may not work for another. We know that eating disorders can look completely different from one person to another.⁹⁴ Likewise, app usage and outcomes will also look different from one person to another. All of the benefits and challenges of eating disorder recovery app use will manifest differently in different user circumstances. Interestingly, the idea of personalization and customizability as an app feature is a common theme in research studies. For many eating disorder recovery app users, the biggest concerns relate to whether apps can be individualized to their symptoms/diagnosis, type of treatment, stage of treatment, and specific needs.⁹⁴ Many eating disorder recovery apps can be used in various ways, but they do not all have the capability to be personalized. As described above, apps can fall anywhere on the spectrum: from supportive and helpful to obstructive and harmful.^29,79. Bearing this in mind when choosing and trying out apps is important so that users aren’t overwhelmed. A “trial and error” approach may be necessary to find the app that works. 

While the COVID-19 pandemic has renewed interest in telehealth, the field of eating disorder treatment apps is not new. Smartphone apps offer substantial potential to extend access to treatment. Several existing smartphone apps have been developed specifically for individuals with eating disorders. Such apps may be a treatment option worth considering as a first step toward getting help for disordered eating or in addition to in-person/telehealth treatment to increase support between sessions. However, more research on these apps is needed to evaluate their use. They should be rigorously evaluated and discussed with a clinician (if possible) before use. Individuals with eating disorders, their caregivers, and treatment providers should do their homework before using these apps, and keep an eye out for new developments in the field throughout the pandemic and beyond!⁹⁵

For More Information: 

Scientific Publications

• Review of smartphone applications for the treatment of eating disorders, European Eating Disorders Review Link
• Apps and eating disorders: A systematic clinical appraisal, The International Journal of Eating Disorders Link
• Smartphones in mental health: A critical review of background issues, current status, and future concerns, International Journal of Bipolar Disorders Link
• COVID-19 and telepsychiatry: Development of evidence-based guidance for clinicians, JMIR Mental Health Link
• Technology and Mental Health: A Clinician’s Guide to Improving Outcomes Link

Resources for Finding and Evaluating Evidence-Based, Expert-Endorsed Mental Health Apps

• American Psychiatric Association App Advisor Link
• Current Psychiatry article summarizing the American Psychiatric Association’s App Evaluation Model Link
• One Mind PsyberGuide Link
• Anxiety and Depression Association of America mental health app reviews Link
• S. Department of Veterans Affairs Mental Health VA App Store Link

Highlighting Popular Apps for Eating Disorder Recovery* 

*Using the site 42matters, a mobile app store data analytics provider,⁶⁸ we searched for apps in the Google Play Store and the iOS App Store that included eating-disorder-related terms in the title and/or description. The following search terms were used: “eating disorder,” “eating disorders,” “anorexia,” “anorexia nervosa,” “bulimia,” “bulimia nervosa,” “binge eating,” “binge eating disorder,” “night eating syndrome,” “avoidant restrictive food intake disorder,” “purging disorder,” “OSFED,” “EDNOS,” “disordered eating,” and “body image.” Apps were sorted by the number of ratings provided by users and by frequency of downloads to identify the most popular apps. We omitted apps not directly related to eating disorder assessment and/or treatment (e.g., role playing games; medical dictionaries; complementary/alternative medicine resources; photo editors; urgent care/medical consultation services; and tracking tools for weight loss, keto, FODMAP, or intermittent fasting diets). We also omitted mental health assessment and/or treatment apps that were not specific to eating disorders (e.g., general peer support tools, therapy packages intended broadly for mood/anxiety and related disorders).

**Download frequency from Google Play Store only; iOS App Store data unavailable

About the authors:

Emily Presseller, BA is a first year clinical psychology doctoral student at Drexel University in Philadelphia, Pennsylvania, working under the mentorship of Adrienne Juarascio, PhD. Her research interests include predictors of illness trajectory and applying novel technologies to the research and treatment of eating disorders. Follow her on Twitter: @EmilyPresseller

Kelsey E. Clark, MS is a fourth year clinical psychology doctoral candidate at Drexel University in Philadelphia, Pennsylvania, working under the mentorship of Adrienne Juarascio, PhD. Kelsey is active in eating disorders research, clinical work, and advocacy. Kelsey’s research is focused on improving eating disorders treatment and understanding emotion-related processes that maintain eating pathology. Follow her on Twitter: @KelseyEClark

Emily Presseller, BA and Kelsey E. Clark, MS work under the mentorship of Adrienne Juarascio, PhD as part of the Drexel University Center for Weight, Eating and Lifestyle Science (WELL Center). Dr. Juarascio’s work centers on the development of innovative treatments for eating disorders, emphasizing acceptance-based and technology-supported approaches. Dr. Juarascio’s work is funded through the National Institutes of Health, the Hilda and Preston Davis Foundation, the National Eating Disorders Association, and the Clinical and Translational Research Institute. Ongoing projects include: The Acquire Project (NIMH R34), which examines a novel smartphone app designed to improve skill acquisition and utilization in cognitive-behavioral therapy for bulimia nervosa; and Sense Support (NIMH SBIR), which uses passive continuous glucose monitoring to predict binge eating and purging behaviors as part of treatment for binge eating. To learn more about her work: Link, Link, Link, Link, Link, Link

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