Leah M. Parsons

Objective: Food insecurity is increasingly linked to binge eating and weight‐related health issues like type 2 diabetes mellitus, but no eating disorder interventions have been tested among individuals with food insecurity. We conducted a single‐arm pilot test of FoodSteps‐FI, a guided self‐help digital intervention for binge eating adapted for food insecurity, among adults with food insecurity, recurrent binge eating, and type 2 diabetes mellitus. Our aims were to test the feasibility and preliminary efficacy of FoodSteps‐FI delivery. Method: Participants were 31 non‐pregnant, English‐speaking adults (≥ 18 years old) with self‐reported type 2 diabetes mellitus, recurrent binge eating (≥ 12 episodes in the past 3 months), and past 30‐day food insecurity who were interested in intervention and owned a smartphone with internet access. All participants received FoodSteps‐FI with messaging‐based coaching (~2×/weekly) for 16 weeks, and a weekly stipend. Participants completed assessments at mid‐intervention (8 weeks) and post‐intervention (16 weeks). Intent‐to‐treat analyses assessed feasibility and changes in clinical outcomes from baseline to post‐intervention. Results: The trial demonstrated feasible recruitment, high study retention, and high intervention completion, adherence, and ratings of usability. Participants achieved improvements in binge eating, weight, past 30‐day food security status, eating concerns, shape concerns, weight concerns, eating disorder impairment, depressive symptoms, shame, and guilt. Nearly all participants rated the stipend as helpful for making behavior changes, but substantially fewer said it was sufficient. Discussion: This pilot trial demonstrated the early promise of an adapted digital binge‐eating intervention for this population, and the need for future research on its effectiveness and implementation.

Background: Testimonials from credible sources are an evidence-based strategy for behavior change. Behavioral health interventions have used testimonials to promote health behaviors (eg, physical activity and healthy eating). Integrating testimonials into eating disorder (ED) interventions poses a nuanced challenge because ED testimonials can promote ED behaviors. Testimonials in ED interventions must therefore be designed carefully. Some optimal design elements of testimonials are known, but questions remain about testimonial speakers, messaging, and delivery, especially for ED interventions. Objective: We sought to learn how to design and deliver testimonials focused on positive behavior change strategies within our multisession digital binge eating intervention. Methods: We applied human-centered design methods to learn users’ preferences for testimonial speakers, messaging, and delivery (modalities, over time, and as “nudges” for selecting positive behavior change strategies they could practice). We recruited target users of our multisession intervention to complete design sessions. Adults (N=22, 64% self-identified as female; 32% as non-Hispanic Black, 41% as non-Hispanic White, and 27% as Hispanic) with recurrent binge eating and obesity completed individual interviews. Data were analyzed using methods from thematic analysis. Results: Most participants preferred designs with testimonials (vs without) for their motivation and validation of the intervention’s efficacy. A few distrusted testimonials for appearing too “commercial” or personally irrelevant. For speakers, participants preferred sociodemographically tailored testimonials and were willing to report personal data in the intervention to facilitate tailoring. For messaging, some preferred testimonials with “how-to” advice, whereas others preferred “big picture” success stories. For delivery interface, participants were interested in text, video, and multimedia testimonials. For delivery over time, participants preferred testimonials from new speakers to promote engagement. When the intervention allowed users to choose between actions (eg, behavioral strategies), participants preferred testimonials to be available across all actions but said that selectively delivering a testimonial with one action could “nudge” them to select it. Conclusions: Results indicated that intervention users were interested in testimonials. While participants preferred sociodemographically tailored testimonials, they said different characteristics mattered to them, indicating that interventions should assess users’ most pertinent identities and tailor testimonials accordingly. Likewise, users’ divided preferences for testimonial messaging (ie, “big picture” vs “how-to”) suggest that optimal messaging may differ by user. To improve the credibility of testimonials, which some participants distrusted, interventions could invite current users to submit testimonials for future integration in the intervention. Aligned with nudge theory, our findings indicate testimonials could be used as “nudges” within interventions—a ripe area for further inquiry—though future work should test if delivering a testimonial only with the nudged choice improves its uptake. Further research is needed to validate these design ideas in practice, including evaluating their impact on behavior change toward improving ED behaviors.

Objective: Food insecurity is associated with eating disorder psychopathology. This Spotlight describes why food pantries could be promising partners for disseminating and implementing eating disorder interventions.Method: Researchers are increasingly collaborating with community‐based organizations to improve access to health interventions, because community‐based organizations overcome structural barriers to traditional healthcare by being embedded physically in the communities they serve, convenient to visit, regularly frequented, and led by trusted community members.Results: We describe strategies we have identified with our partner to disseminate and implement our digital intervention for binge eating; we also discuss ways we support the pantry's needs to improve the mutuality of the partnership.Discussion: The potential benefits of partnerships with food pantries make this an area to explore further. Future research directions include deeply engaging with food pantries to determine how pantries benefit from disseminating and implementing eating disorder interventions and how to intervene in non‐stigmatizing ways, what resources they need to sustainably support these efforts, what eating disorder intervention modalities guests are willing and able to engage with, what intervention adaptations are needed so individuals with food insecurity can meaningfully engage in eating disorder intervention, and what implementation strategies facilitate uptake to intervention sustainably over time.