BALANCE MOBILE APPLICATION:
Management of Self-Monitoring Based Treatment
in Restrictive Eating Disorder Patients
Megan Faletra | Mobile Health Design
Final Paper
July 6th, 2015
Executive Summary
Smartphone applications have become increasingly more popular in the treatment and
management of a variety of health concerns as more than 50% of the adult population in the
United States now possesses a smartphone.1 From sleep disorders, to obesity, to depression,
smartphone mobile applications have begun to take the healthcare marketplace by storm,
opening up an entirely alternative means of treatment for conditions that require a substantial
level of continuous treatment, monitoring, and patient self-efficacy.2 While mobile applications
addressing weight loss, and exercise have become well accepted by society with mobile
applications such as MyFitnessPal reporting upwards of 80 million user downloads, health
professionals in the psychiatric community are still debating how mobile applications could be
both hurting and helping those individuals struggling from eating disorders, particularly those
that focus around restrictive eating such as anorexia nervosa, bulimia nervosa, or orthorexia
nervosa.3
This paper serves to focus on the proposal of a smartphone mobile application – Balance –
which has the overarching objective of aiding in the successful self-monitoring aspect of
treatment in individuals suffering from restrictive focused eating disorders. The application will
primarily target those individuals suffering from anorexia nervosa, bulimia nervosa, and
orthorexia nervosa, all of which have consistent restrictive eating tendencies.4 Using evidence
based guidelines and cognitive behavioral therapy Balance will be designed to address the
specific needs of the identified target population, and will ultimately allow for individuals
suffering from eating disorders to self-monitor their eating behaviors, in conjunction with an
eating disorder support team that consists of a therapist, primary care physician, and registered
dietitian.5 In order to ensure compliance with current medical best practices for the treatment
and management of restrictive eating disorders, the application will be designed in partnership
with the National Eating Disorder Association, as well as the American Medical Association,
American Public Health Association, and American Psychiatric Association.
The design of the mobile application will focus on avoiding identified negative components
associated with traditional paper-and-pen food journaling (also referred to as self-monitoring)
for eating disorder patients, and obsessive caloric and macro-micro energy nutrient tracking
that exists in food tracking applications in the current mobile health marketplace. Ideally
Balance will have the ability to provide the eating disorder patient with a means of moving
slowly towards a balanced energy state, and away from a life of extreme restriction. In addition,
the application will allow for health care professionals to have a clear understanding of how
their patient is doing on a daily basis, this will increase treatment efficiency during face-to-face
treatment sessions, and will allow for some of the treatment barriers associated with eating
disorders to be removed.6 7
The proposal of the mobile application Balance for the treatment and monitoring of restrictive
eating disorders will be supported and presented in this paper by means of an extensive
background and needs assessment of the use of mobile applications for the treatment and
monitoring of eating disorders. Additionally, a series of personas will be used to further
exemplify the needs of this population, and a competitive analysis will be conducted in order to
showcase the current applications available in the mobile health marketplace. The design of
Balance will be showcased with the use of wireframes in order to provide a visual understanding
of the patient and clinician user functionality. Lastly, an evaluation plan, development plan,
marketing plan, and outline of limitations will be provided for the purpose of showcasing the
realistic expectations of this application’s place in the current mobile health marketplace.
Lastly, in order to ensure patient/provider confidentiality, the application will be protected with
electronic security software current being used to protect electronic medical records. It has
been determined that in order to reach the largest number of eating disorder patients, the
application will be made compatible with both Apple iOS and Android smartphones.
Additionally, a supplemental website will be made accessible for those individuals who may not
own a smartphone.
Background
Eating Disorders and Mobile Health Application
Although mobile applications have only been in existence for under a decade, there are already
over three million applications available on the marketplace, with many applications falling into
the “mobile health “ category.8 At this time, roughly one fifth of all smartphone users have
downloaded at least one health-related application, and that statistic is expected to rise to
reach 50% in the next three years.8 While many mobile applications aim to address weight loss,
exercise, anxiety disorders, depression, or even addictions such as excessive alcohol use, the
marketplace for mobile health applications targeted for people suffering from eating disorders
has lagged significantly behind.9
Of the over three million applications currently available for download, only 39 have been
determined to be designed specifically for people suffering from an eating disorder.8 Of those 39
applications, in a systematic clinical review by Fairburn and Rothwell only eight of the 39
applications had been downloaded more than 5,000 times, and only five of the applications
provided sound information and support. Many of the applications were determined to have
less than adequate information for a person suffering with an eating disorder, and some even
bordered on providing harmful information.8
One perceived reason for the lack of mobile health applications suited to meet the needs of a
person suffering from an eating disorder, specifically a restrictive eating disorder, is that in many
cases mobile health applications work as enabling tools for eating disorder patients with
obsessive compulsive tracking and restrictive tendencies.10 11 Many of the mobile health
applications on the marketplace, such as MyFitnessPal, make it seamless for people with eating
disorders to obsessively track and count their calories, macro and micro-nutrients, and energy
expenditure.12
Status of Eating Disorders in Western Culture
Eating disorders have been characterized by “a severe and persistent disturbance in the eating
behavior that causes psychosocial and, sometimes, physical impairment”.6 Currently the DSM-IV
is used as the classification tool for recognizing and diagnosing anorexia nervosa, bulimia
nervosa, and eating disorder not otherwise specified (NOS), which encompasses orthorexia
nervosa. Anorexia nervosa and bulimia nervosa have been considered to be primary psychiatric
disorders, which are characterized by the severe natural disturbance of a person’s overall eating
behavior.11 More recently (in the past decade) orthorexia has also been classified as a clinical
eating disorder focused around the obsession for healthy foods. Particularly in Western cultures
eating disorders are found to be more prevalent where female beauty is equated with
attractiveness, and food is of abundance.11
Of the varying eating disorders, anorexia nervosa is a type of eating disorder, which is marked by
an inability to maintain a healthy body weight, and extreme restrictive tendencies around food.
Bulimia nervosa, also is associated with some form of restrictive tendencies, but is also coupled
with recurrent episodes of binge eating and some form of purging either through vomiting,
laxatives, or obsessive exercising. Lastly, Orthorexia is classified by an unhealthy obsession with
healthy foods that affects a person’s ability to maintain a healthy diet, and weight balance.11
Mortality rates, specifically in anorexia nervosa patients, are among the highest across all
mental disorders, and although there have been a variety of evidenced based best practices for
the treatment and management of eating disorders, very little progress has been made in this
field, mostly due to patients reluctance to seek help and undergo treatment.11 Knowing that
there is a great need for better tools and resources to help with the treatment of individuals
who are reluctant to seek out psychiatric treatment, a look at the current evidence based best
practices and a needs assessment based on eating disorder symptoms, was needed in order to
determine how the Balance mobile application could be most effective for this population.
Evidence Based Best Practices for the Treatment of Eating Disorders
In the management of eating disorders there have been a number of interventions that have
been proven to support the recovery of a patient suffering from an eating disorder. One of the
most effective methods of treatment has collectively been determined to be the use of a
multidisciplinary approach involving a team of licensed practitioners. This team should include a:
psychiatrist, psychologist, endocrinologist, dentist, gastroenterologist, primary care physician,
and registered dietitian. It is critical for all of these personal to work closely together, especially
the primary care physician, psychiatrist, psychologist, and registered dietitian in order to ensure
that the patient’s needs are being addressed on a medical, nutritional, and mental level. When
these three forms of treatment work in alignment with one another, the likelihood for a
person’s successful recovery becomes much greater.11 13
Cognitive-Based Therapy (CBT) has also been proven to support the treatment and recovery of
eating disorder patients, specifically those suffering from bulimia nervosa. CBT works by initially
working towards maintaining the current level of eating disorder in a patient, and working
through a series of stages to slowly transition the patient into a healthier state.6 During the first
stage of CBT the main objective is working on engaging the patient in the overall treatment and
behavior change plan. This encompasses jointing formulating what the patient’s disordered
behaviors are, and developing a plan that feels manageable to the patient and therapist. The
establishment of self-monitoring is then put in place, which is a style of treatment that has been
incorporated into more eating disorder treatment plans. This self-monitoring approach asks the
patient to record what they eat, how they feel, and what negative behaviors may occur around
eating.6 For instance, the patient should record if they restrict, purge, how much they eat, how it
made them feel, etc. Although this method of treatment can be very successful in allowing the
patient and care-provider to gain a better insight into the patients routine, in general this selfmonitoring can be difficult for most patients to maintain. In CBT it is also important to
determine a pattern of regular eating, and collaborative weighing that allows the patient to still
weigh his or herself, but in the presence and support of a care-provider. The main portion of
CBT does occur in the final stage of treatment however, where the over-evaluation of shape and
weight is addressed. This area usually requires the longest amount of time, and encompasses a
person’s overall self-worth, and self-efficacy.6
In addition to CBT, person-centered informed decision-making, and involving family and
significant others have also been found to benefit the recovery of a person with an eating
disorder.13 By allowing them to make some of the informed choices surrounding their recovery
and treatment the patient feels less like they are losing control of their current situation, and
their eating disorder. It also is important to include family and significant others in this process
in order to ensure that they are capable of supporting the person with the eating disorder in a
way that feels comfortable, and not overbearing.13
Lastly, it is important to find the least restrictive treatment context for the patient to work
within if treatment and recovery is going to be successful and maintainable. Since many
individuals with eating disorders have an extreme fear of giving up their eating disorder, or deny
their disorder behavior entirely, it is crucial to allow for them to be treated when possible in a
setting that feels comfortable to them. Outpatient treatment can be defined for the patient in a
stepped and seamless care model, that allows for the patient to make small-incremental
changes that they feel comfortable with. Understanding that relapse is very common in eating
disorder patients it is important for the patient and care providers to have an open dialogue
about the lengthy process that the successful treatment of an eating disorder usually entails.13
Needs assessment
Target population
The target population for this demographic will focus on females and males 18 years and older
who are suffering from a restrictive eating disorder such as anorexia nervosa, bulimia nervosa,
or orthorexia nervosa. The target population is focusing on adults mainly because the 18 +
population tends to go longer without treatment, when compared to the adolescent population
which receives treatment earlier due to parental involvement and routine dental and pediatric
care appointments. Adults who are living away from home, and are in control of their own
medical care, are much more capable of hiding their eating disorder for longer periods of time.
While a parental permission feature will be built into the Balance application in order to allow
for adolescents to access the application, the primary target audience will remain in 18 +
females and males.
While the characteristics and behaviors of people with eating disorders have been well
researched and published, the effect mobile health applications can have on the treatment of
eating disorders is still in its early stages. In order to gain a full understanding of the various
characteristics, behaviors, and triggers associated with restrictive eating disorders an extensive
literature review will need to be conducted before any application design can take place.
Additionally, consultants will need to be determined from the clinical, psychological, and
nutritional perspective. These consultants will act as key informants during the actually design
of the Balance application, and will work collaboratively with one another.
As the application is being designed it will also be important to recruit patients with eating
disorders to partake in the design of the application. It will be important to work with patients
who are in a current maintenance stage of recovery, and who can provide reflective feedback on
what was useful in their treatment. These focus groups, and key informant interviews will lay
the foundation for the programs treatment design, with the objective of creating an application
that is safe, and effective in treating restrictive food behaviors in a variety of eating disorder
patients.
Assessment of Eating Disorder Characteristics
Eating disorders are frequently thought to occur only in women, however it is important to note
that while eating disorders are disproportionately present in women, they can occur at any age,
and within any gender, or race. Additionally, eating disorders tend to present themselves
concurrently with other mental health disorders such as anxiety disorders, depression, and
obsessive compulsive disorders.13
In the case of most eating disorders, a core psychopathology commonly present is the
overvaluation and level of importance placed on an individuals shape and weight. These
individuals tend to judge themselves based solely on their shape and size, and
disproportionately evaluate their own self-worth based on their control over their body, weight,
and perceived image. While other individuals may perceive their self-worth based on a number
of factors, such as: work, relationships, friends, school, etc., people with eating disorders tend to
struggle with a body dysmorphic disorder, and have a very difficult time separating their own
self-worth from their body size, and weight.6
Specifically, with anorexia nervosa patients, these patients are usually highly secretive when it
comes to their eating disorder and will present with high levels of anxiety around treatment.
Symptoms of anorexia nervosa most commonly include, but are not limited to: dietary
restriction, extreme and sudden weight loss, loss of menarche, inability to gain weight, binging,
purging, excessive exercising, use of laxatives, constipation, insomnia, social anxiety, depression,
and fatigue.13 Patients with bulimia nervosa tend to resemble patients with anorexia nervosa in
terms of their overall eating habits and methods of weight control, however patients with
bulimia nervosa recurrently disrupt their cycles of food restriction with binge/purge episodes
that can result in a perceived level of weight maintenance.6
Lastly, patients with orthorexia nervosa will have similar restrictive food habits that can result in
sudden weight loss, however their concentration lies in an obsession around the consumption of
healthy foods, which eventually can become so extreme that very few foods feel safe for the
person to eat, resulting in a highly restrictive eating behavior.10 Individuals with orthorexia
nervosa experience severe anxiety when eating in social situations, at restaurants, and fear the
consumption of “non-healthy foods”.10
Personas
Amy
About Amy
Amy is 24 years old and works as an editorial assistant for a fashion
magazine. She loves fashion and has done some editorial modeling for
the company’s fashion magazine. There is a lot of pressure in Amy’s
office to always look her best, and be wearing current new fashion
designs. Around the office, many of her co-workers are extreme dieting
and trying to lose weight. Amy has a history of anorexia nervosa, and
has been in treatment in the past, once during high-school and again
during college. Although Amy has been in recovery for the past two
years, her anorexia has begun to re-surface.
Eating Disorder
Anorexia Nervosa
Behaviors
For the past six months, Amy has begun to drastically restrict her diet. It
began when she knew that she was going to be modeling in a fashion
show for her company’s magazine. Before the fashion show she began
to cut back to one meal per day, and started working out for one hour
per day. She started to lose weight quickly, and after the fashion show
she found herself unwilling to go back to her healthier eating habits.
She continued restricting her diet, and continued to lose weight.
Amy does not track her meals, however she has become so good at
calorie counting over the years that she is able to count and track her
calories for the day in her head. On average, Amy tries to keep her food
under 800 calories. She manages to do this by skipping lunch and
breakfast, having a small snack during the day, and then has a small
dinner. Amy chews a lot of gum, and drinks a lot of diet soda in order to
help control her food cravings.
Amy is usually able to restrict her meals for about five days; at what
time she then will binge. Occasionally, Amy will purge her food after
binging, but on most occasions she doesn’t eat for an entire day after a
binge.
Since her eating disorder re-surfaced, Amy has gone from weighing
herself once per month, to once per week, to everyday.
Current Treatment
Amy has been in therapy for her eating disorder in the past, and is in
the process of beginning therapy again. Amy has never seen a
registered dietitian, but is open to the idea.
Amy’s Balance App.
Usage
Amy has used tracking apps in the past, as well as fitness apps, however
in her past therapy her therapists made it clear that these tracking
applications may not be the best thing for her, and that she should
avoid using mobile applications for food tracking. Recently, Amy’s
family has noticed that she has been losing weight again quickly, and
avoiding meals. Her Mom decides to talk to Amy about her eating
habits, and they both agree that it would be good for Amy to start
seeing her therapist again. Amy decides that this time around she
would also like to see a dietitian in order to develop better eating
behaviors, and come up with better ways of managing her stress
around her weight and food.
When Amy contacts her therapist to make an appointment, her
therapist asks her to download the Balance app and begin to use the
application to track her current eating habits and behaviors. At first
Amy feels skeptical about using an app, since she always associated
them with extreme restricting, however she tells her therapist that she
will give it a try. Quickly Amy realizes that Balance is unlike any tracking
app she had ever tried before, and realizes that her eating disorder is
more extreme than she has originally been aware of. Amy likes the apps
ability to just tap her food, and appreciates that as she uses it the app
begins to remember what she commonly likes to eat, making tracking
even easier.
In the past Amy never had luck with typical food logs for tracking her
consumption because she would be embarrassed to write down that
she purged, or didn’t eat anything but gum and diet soda for two days.
With the Balance app she doesn’t feel that same sense of guilt, since
when she does restrict all she has to do is tap the restrict button. Not
having to actually write in her meals/behaviors has made it easier for
Amy to record her behaviors honestly. She is also a very visual person
and likes seeing the graphs that show how consistently she is
participating in some negative health behaviors.
Sarah
About Sarah
Sarah is a 40 year old mother of three young children ages 7, 5, and 3.
She lives in an affluent community and is a stay at home mom. When
her middle child was diagnosed with autism, she began to read about
how autism can be better managed through various diets. She began to
cut all wheat, dairy, and refined sugar out of her diet and her children’s
diets. When she became pregnant with her youngest child, she became
even more obsessed with what she was eating, and tried to maintain as
“clean” of a diet as possible, mostly with the hope of preventing autism
in her youngest child through her healthy eating habits. She only
consumed organic foods, and avoided almost all grains. Her
gynecologist was concerned that Sarah was not gaining enough weight
during her pregnancy. Once her youngest child was born Sarah
continued to eat as “clean” as possible, and became even more
obsessed over where her food was sourced. Although she would buy
organic meat and dairy products for her family, she stopped eating all
meat and dairy, as well as continued her gluten free/sugar free/grain
free diet. Sarah over the course of three years since her youngest child
was born dropped from a healthy BMI of 24 to an unhealthy BMI of 17.5
Eating Disorder
Orthorexia Nervosa
Behaviors
Sarah loves to track her food and uses myfitnesspal and her fitbit
religiously to track her micro/macronutrients, as well as all of her
exercise. She works out at least once a day, and usually attends a power
hot yoga class. She drinks her breakfast and lunch in the form of green
juice, and completes a week-long juice cleanse once per month. She
currently follows a 100% organic, raw, vegan, gluten free diet, and
avoids all processed foods, and anything that contains any refined
sugar, or artificial sweeteners.
Sarah feels extreme anxiety when eating out in public and usually tries
to avoid eating at restaurants where she cannot verify how her food
was sourced. When she does eat something that she cannot verify if it
contained sugar, or was organic, she begins to feel extreme anxiety
around the food choice and will usually take two power yoga classes a
day for three days to “sweat out the toxin”, or will go on a juice cleanse.
Sarah’s family is concerned for her well-being, and while her children
are healthy, Sarah has noticeably lost a significant amount of weight
and has become a much more anxious person. However, because Sarah
always talks about how healthy her food choices are, and does eat
regularly (just in small “clean” quantities), it is unclear to her family and
friends whether Sarah has an eating disorder, or is just “very healthy”.
Current Treatment
Sarah currently is not receiving any treatment for her eating disorder
and has not really come to terms herself with the fact that she in fact
has an eating disorder and needs help.
Sarah’s Balance App.
Usage
One day Sarah was getting a green juice after a power hot yoga class
with her yoga instructor/friend. While they were sitting and talking her
instructor opened up the Balance app and within a minute has tapped a
few buttons and entered in her AM Snack. Sarah had asked her
instructor what app she was using to track her food since Sarah loved to
track, and her instructor began to tell her about how she was actually
going through treatment for orthorexia nervosa. She explained to Sarah
how when she became a yoga teacher, she also became much more
obsessed with living a healthy lifestyle and began to form eating habits
that were much too restrictive. When she lost her period after losing
too much weight, her instructor told Sarah that she had sought out
therapy and a dietitian and her current dietitian was actually the one
who recommended the Balance application. She explained to Sarah
how helpful it had been on helping her recover, and live a more
balanced life around food.
After Sarah left her friend and the juice shop, she began to reflect on
how restrictive her own habits had become, her body weight, and
whether she may or may not have a similar problem. She downloaded
the application, and was quickly connected with a therapist and
dietitian in her area. Within minutes, she had an appointment
scheduled and had already tracked her first meal. Immediately she
realized that her extreme longing to know exactly how many calories,
and the nutritional breakdown of her juice, may in fact not be healthy
and she became open to the idea of seeking therapy, and using the
Balance app to continue to track her meals, but maybe in a less
obsessive manner.
Matthew
About Matthew
Matthew is 17 years old and is a high school wrestler. He is currently
ranked number three in his division and has been training intensely for
his senior year. Matthew’s family does not have the money to send him
to college, and so Matthew is hoping to land a scholarship for wrestling,
which would allow him to go to college without digging himself into a
large amount of debt. Matthew has been wrestling since he was 10
years old, and has become accustomed to the behaviors needed to be a
top wrestler. Over the past few months Matthew has lost 10 pounds to
reach 135, and has developed very restrictive eating habits that have
begun to worry his friends and family.
Eating Disorder
Bulimia Nervosa
Behaviors
Currently, Matthew is trying to drop into a lower weight bracket and
has begun to take some extreme measures to drop his weight. Matthew
is 5’7” and currently weighs 135 pounds, he is trying to drop into the
125 pound bracket, and is looking to lose 10 pounds before his senior
year begins. In order to do this Matthew has been restricting his diet,
and usually will only consume one egg for breakfast, a few starbursts
before practice, and then a protein shake for dinner. Matthew has
begun to avoid all social meals, and has become much more isolated.
An average day for Matthew usually consists of him working out in the
morning, going to school, skipping lunch and running to lose water
weight during lunch, going to practice in the afternoon, and then either
eating a small dinner, or drinking a protein shake.
Almost every 3-5 days Matthew will break down and binge on some
food, usually carbs, and after with either purge or take a laxative. These
habits have been on-going for Matthew over the past three months,
and his family and coaching team are beginning to become worried.
Current Treatment
Matthew is currently not receiving any treatment, and is not open to
changing his behavior until after he has landed a college scholarship.
Matthew’s Balance
App. Usage
Matthew was pulled aside by one of his coaches when Matthew nearly
fainted during a practice. His coach began to ask him about his eating
and hydration habits, and how much he had been working out. The
coach was concerned by some of Matthew’s answers and decided to
include the school counselor, and Matthew’s parents in on the
discussion around Matthew’s health, and his place on the wrestling
team. Matthew’s parents, the coach, and school counselor all agreed
that as long as Matthew was healthy enough to wrestle he should still
be allowed to, however Matthew would need to agree to counseling in
order to keep his spot on the team.
Since Matthew was very hesitant to start therapy, his coach and school
counselor thought that it may be good for Matthew to begin by tracking
his behaviors and meals with the Balance application (with the approval
of his parents) and work with the school counselor, and coach on how
to create a safer training and eating regime. While Matthew’s parents
were working on finding him a therapist who he connected with, the
school counselor and coach worked on reviewing Matthew’s food logs.
Matthew began to realize that he actually did have an eating disorder,
but wasn’t sure what to do since he was so stressed about getting a
college scholarship for wrestling. After finding a therapist and sports
nutritionist who specialized inn eating disorders in athletes, Matthew
was able to share his food and behavior logs with the therapist and
dietitian in order to determine what the best plan of action would be,
that wouldn’t compromise his performance or his health.
Jennifer
About Jennifer
Jennifer is 20 years old and is a sophomore in college. She also runs for
her college cross-country team, and is on a scholarship for school.
Jennifer is 5’5” and weighs 130 pounds, she would like to weigh 105
pounds or just under 100 pounds. When Jennifer lost 10 pounds after
high school she noticed that her speed increased in her running. As one
of her teams top runners, Jennifer feels a lot of pressure to perform her
best at all times.
Eating Disorder
Bulimia Nervosa
Behaviors
Jennifer eats roughly 1000 calories per day and is 5’5”. She eats a
granola bar in the morning, a salad for lunch, drinks a lot of diet soda,
and has lean chicken and veggies for dinner. Jennifer doesn’t like to eat
around other people and her friends notice that she doesn’t eat with
them in the cafeteria for dinner or lunch very much anymore. Jennifer
restricts her diet from a set of designated “bad foods”, and ultimately
binges about 3-5 times per week, after a day of extreme restricting.
Jennifer exercises 2-3 times per day. She always exercises with her
cross-country team, which usually consists of a 1.5 hour long practice of
running 5+ miles and some light weight-lifting. She will also spend 1
additional hour on the treadmill each day, and will sometimes take a
spin or hot yoga class to get her third workout in.
In general, Jennifer is mostly stressed by upcoming and important cross
country meets, and her school work. When she is feeling more stressed
she tends to have more extreme episodes of binging and purging.
Current Treatment
Jennifer is currently in treatment for her bulimia. She was required to
seek treatment in order to stay at school and avoid medical leave. While
she is being monitored she is still allowed to run for her cross-country
team, however if any of her vitals drop to a level that is perceived as
dangerous she will not be allowed to race and practice until she is
cleared by her medical team. Jennifer is also currently seeing her
college dietitian, this also is mandatory from her school and sports
coach in order to avoid medical leave and remain on her cross-country
team.
Jennifer’s Balance
App. Usage
Jennifer loves health apps and tracks all of her activity with fitbit. She
also wears a heart monitor to ensure that she is receiving accurate
caloric burn data, however once she bagan therapy Jennifer was asked
to delete all apps that could increase her restrictive habits such as
myfitnesspal, and has been asked by her dietitian to download the
Balance app instead for tracking her meals. Jennifer has found the
Balance app to be somewhat frustrating because she wants to know all
of her caloric intake and energy balance, however she has become
more aware of just how often she is binging and purging.
Jennifer isn’t really committed to recovery at this time, but is really
bothered by her binge/purge episodes, and is frustrated by the fact that
she doesn’t seem to be losing weight. She has also noticed from the
Balance app that her self-image every single day is very poor, and she is
feeling depressed. Her therapist and dietitian have been noticing an
increase in binge/purge episodes from her Balance tracking and have
been working with Jennifer on ways in which she can decrease the
number of binge/purge episodes she has in a week.
Lessons Learned from Personas
After completing the personas, it became apparent that due to the simplistic nature of the
Balance application it was possible for the app to help those patients who were open to
therapy, as well as patients who were not yet willing to let go of their disordered eating.
Additionally, stigma and guilt was a common theme that seemed to come up throughout the
different personas. This self-inflicted guilt around purging is something that needs to be given a
great deal of attention in the design of the app, and it was determined that the less time it takes
for a person to enter in his or her food and behaviors, the more likely it will be that accurate
information is provided.
Competitive analysis
A competitive analysis of pre-existing restrictive eating disorder focused mobile health
applications was conducted in order to determine what applications are currently performing
the most efficiently, what applications are not performing well at all, how evidence based
practice is being filtered in current eating disorder mobile health applications, and how the
Balance application can be more effective for the identified target audience’s needs. For this
analysis three of the most downloaded and applicable applications designed specifically for
restrictive eating disorder patients were analyzed.
It was difficult to find a minimum of three applications that actually focused on addressing
restrictive eating disorders. While many applications would focus on binge eating and weight
loss; there was a very limited inventory for addressing extreme restrictive eating behavior. Most
applications in the current mobile health marketplace seem to focus more on the anxiety and
mood aspect that is associated with eating disorders, and less on addressing self-monitoring of
eating habits in a healthy, supportive manner for successful treatment. Three applications were
determined however to provide a means for safer tracking of food intake specifically for eating
disorder patients. The results of the competitive analysis can be seen below in Table One.
Table One: Eating Disorder Mobile Health Applications Competitive Analysis (30 minutes)
Rise Up + Recover
(1)
Emotes for Disordered Eating
(2)
Recovery Record
(3)
The application’s main
objective is focused on
addressing self-monitoring as a
form of treatment for
individuals struggling with
disordered eating or body
image issues
Emotes for disordered eating, is
a self-monitoring log for those
who have been or are currently
undergoing treatment for eating
disorders.
Recovery Road is the
smartphone companion for
managing treatment and
recovery from an eating
disorder. The application is
intended for people with
general eating, weight, and
shape concerns.
The purpose and goals of the
application based on its name,
tagline, and imagery are not
explicitly focused towards
disordered eating, however it
is apparent from the name that
a person who is downloading
this application would be in
need of some form of
recovery. The tagline, although
long, does clearly outline what
the application can be used for
and what the overall purpose
is.
The purpose of the application is
to aid those going through
treatment for an eating disorder
through self-monitoring. While
this is not clear from the image
or name, it becomes clear once
you enter into the application or
read the applications description.
The name expresses that there
is some form of recovery that
is involved in this applications
purpose, however the imagery
and colors are not reminiscent
of anything that would be
associated with medicine or an
eating disorder.
This application is very much a
bare bones application, and is
simple and easy to figure out
within minutes of opening.
The tagline directly ties into
the overarching purpose of the
application, making the
somewhat vague name and
imagery clearer.
Mobile Application
Logo Design
Objective at a glance
What is the objective,
problem, or challenge
the app or device
seems to be
addressing?
Purpose and Goals
How clear are the
purpose and goals of
the app or device at a
glance from name,
tagline, and imagery?
Does it match the
objective at a glance?
Tagline:
“An Eating Disorder
Monitoring and Management
Tool for Anorexia, Bulimia,
Binge Eating, and EDNOS”
Tagline – Eating Disorder
Management
Users
Is there any
information about
users through
descriptions, images,
stories, testimonials,
or usage data?
Ratings and reviews
What are the ratings,
reviews, and
feedback?
Users are mostly depicted on
their supplemental website
which shows how many
countries that app has been
downloaded in, and provides
quotes/testimonials of people
who have used the application.
However, these testimonials
do not provide a clear
understanding of the
demographic, gender, race,
etc. being reached most
effectively.
There is not very much
information that gives insight
into what the users are like who
use this application. The reviews
provide very little personal
information, and the most the
description of the application
addresses about users is that
most are likely to be currently
undergoing treatment.
There is not very much user
specific information listed in
the application or
supplemental informative
website. However, it is possible
to get an understanding of the
applications users through
their reviews. Based on
application reviews, a wide age
range uses this application for
a variety of eating disorders.
17 current version user ratings
231 total version user ratings
8 total reviews
3.8 user rating
36 current version user ratings
1,582 total version user ratings
The application has a five star
rating, with very positive user
reviews. Users seem to like the
overall design, user
functionality, and simplicity of
the application. Both males
and females wrote positive
reviews of the positive effects
the motivational quotes, and
meal logging had in their
eating disorder recovery,
which speaks to the overall
gender neutrality of the
application.
Users review the application as
easy and simple to use, with
summary functionality that is
helpful in food logging.
The application has a five star
rating, with very positive user
reviews. Users seem to be
impressed by the overall
functionality of the application,
and the ability the application
has to be customized to a
specific persons needs. Some
people did point out that it
could be even more tailored to
reach an older audience, since
some of the automated
answers to questions seem
geared towards a younger
audience.
Available on Android software
Available in the apple store
Available in the apple store
Downloads and use
How many
users/downloads are
there? Is there data
about retention?
66,000
1000-5000 user downloads
361,000
The developers state on their
website that the application
has been used over 1 million
times, however there does not
seem to be any data pertaining
to retention.
There is currently no data
present on retention rates of
users
There was no retention data
listed on either their mobile
application or website.
However, many who reviewed
the application discussed how
it was helpful in their ongoing
maintenance, which can be
associated with some
application use retention.
Research
Was there any
research, evidencebased guidelines, or
experts involved?
Design
How professional or
attractive is the
design?
Layout and navigation
(for an app)
What sections does
the app have and are
they delineated by
content type, roles, or
user needs? How
usable and organized
are the layout and
navigation (including
labels and menus)? Do
they make options
apparent?
The developers of this
application clearly were well
aware of Cognitive Behavior
Theories (CBT) role in the
treatment of eating disorders,
and self-monitoring. Both selfmonitoring and CBT fall inline
with evidence based
guidelines, however it is still
unclear if/what level of expert
knowledge contributed to the
development of this
application.
There were no evidence based
guidelines specifically listed or
called out on the application
description, however they are
using a self-monitoring format,
which falls in-line with cognitive
behavior therapy.
The design of the application is
incredibly user friendly, with
clear icons, calming colors, and
useful info graphics and images
being used. Overall, it would
appeal to a gender neural
audience, and could be
applicable for use in both
young and older adults, as well
as teenagers.
The design of the application is
sleek, dark, and simple. It allows
a user to track his or her meals,
export the information to print
or share with a therapist, and
also allows for charting of
progress.
The home page of the
application allows for the
individual to either check-in or
export their data for use in a
therapy session.
The app only has five areas to
choose from and one main
navigation. Based on what the
users needs are they will choose
what area of the application they
would like to access, be it the
charting area, exporting, or
logging.
From the home page they can
choose to log meals, look
through coping skills, or
connect to social media.
Overall, as far as an application
A team of psychologists who
desired an application that
could help them connect with
their patients, and make selfmonitoring easier developed
the application.
Cognitive Behavioral Therapy
(an evidence-based guideline)
was used in the foundation of
building this application.
The overall design of the
application appears to be
somewhat outdated by looking
at the font, and overall layout.
Also very bright colors are
being used, which at least in
my opinion is somewhat of a
turn-off.
The application could benefit
from a little better
streamlining in its design to
remove some of the various
tabs users need to go into to
track and monitor their
progress.
The application is very simple
which makes it very user friendly
however it doesn’t provide for
The main interface of the
application is used for meal
logging, and allows the
individual to answers a series
of questions regarding their
eating habits/behaviors. Then
on the left-hand side of the
navigation is where the user
can choose from a much larger
array of options, this is the
main menu for the application
and is somewhat
for tracking meals goes, this
application is user friendly and
allows for the user to target
their own needs by choosing
what they would like to record
such as food, mood, behaviors,
etc.
very much personalization to
take place.
User options are obviously from
the main interface, which does
not have many options to choose
from.
overwhelming.
With more than 20 options to
choose from, the application
could use some streamlining in
its navigation function to make
using the application more
seamless.
The options could use short
descriptions below the icons in
order to make their slightly
more clear, but this also isn’t
perceived to be a major barrier
in user functionality.
Branding and external
affiliations
Who created the app
or device and why? Is
there organizational
branding,
accreditation,
sponsorship, or
advertising?
Expert content
What are the expertgenerated
components, if any,
The app was created by the
“recovery warriors” which
consists of two women, one of
which went through the
process of recovering from an
eating disorder and wanted to
launch an application to help
others recover using selfmonitoring. The Recovery
Warriors manage a blog,
website, and podcast that can
be used in addition to the
mobile application and provide
support for those suffering
from an eating disorder. There
is a clear “recovery warriors”
brand and logo that is
associated with the application
that definitely points
individuals towards their other
resources, however there is no
other advertising or
sponsorships present on both
the application or website.
The application is a self
monitoring log aimed at helping
those who have been or are
currently undergoing treatment
for eating disorders.
Unfortunately, this application
does not explain how expertcontent was generated or the
This application does not explain
how expert-content was
generated or the clinical
It is unclear who created the app,
and if they had a specific reason
outside of wanting to create a
space where people undergoing
treatment for eating disorders
could self-monitor with ease.
There is no affiliated
sponsorships or advertising
present.
A group of therapists,
engineers, and entrepreneurs
created the application for the
purpose of aiding people
suffering from eating disorders
self-monitor, and track meal
planning. It also is meant to
help clinicians keep better
account of their patients, and
be able to provide their
patients with better care.
There is no advertising present
on the application or website,
branding is consistent between
the application website and
the application’s mobile user
interface. As far as
accreditation is concerns, the
application is connected to a
network of healthcare
providers, health plans,
researchers, and clinicians who
work on managing the
applications network of
healthcare providers, as well as
the overall functionality of the
application itself.
Expert content is being
generated by partnering health
care providers, the founding
available (including
text, graphics, audio,
video, blogs,
directions, ask the
expert, glossary, quiz,
chat with an expert)?
Does expert content
identify the author and
date written and
reviewed?
Oversight
Is there an advisory
board or clinician
involvement?
Literacy and
readability
Is the content in the
app clear and easy to
understand? What
about any descriptions
or instructions for an
app or device?
clinical credentials behind the
meal logging, motivational
quotes, etc. While the
application is described to tie
into Cognitive Behavior
Therapy practices, there are no
licensed therapists, dietitians,
or clinicians listed in the design
and development of this
application. As far as can be
seen, the creator of the
application does not have any
medical credentials for treating
eating disorders, and her own
experiences seems to the basis
of much of what appears on
the website and application.
credentials behind the meal
logging. There are no licensed
therapists, dietitians, or clinicians
listed in the design and
development of this application.
therapists, participating health
plans, researchers, and
clinicians.
There does not appear to be
any advisory board or clinical
involvement specifically
associated with the
application, its
information/resources, and
overall development. The team
behind the application had
their own experiences with
disordered eating, but do not
hold any clinical credentials.
The application is linked to
Connect ED, which helps
individuals find a licensed
medical professional to help
them with the face-to-face
aspect of their treatment.
There does not appear to be any
advisory board or clinical
involvement specifically
associated with the application,
its information/resources, and
overall development.
There seems to be a best
practices committee working
on the application, but
otherwise there does not
appear to be a specific board
of directors or advisory board.
The very simple nature of this
application makes for very
little instruction/descriptions
to be present in the
application. Where
descriptions are most present
is in the coping skills section
where a person can choose the
kind of skill/motivation that
they are looking for. This
The application is written and
setup in a very straight-forward
simple manner that allows for
very ease literacy and overall
readability.
The content on the application
is clear, however somewhat
overwhelming. While
instructions are written clearly,
the automated responses to
some of the applications are
targeted more at a younger
audience.
The application never really uses
long descriptions for instructions
and overall is designed and
written in a manner to allow for
These “experts” participate in
the development and overall
evidence based practice of the
application. However, the
application and website does
not have a participating blog,
or online community. Experts
are not identified by name.
The information may be clearly
User-generated
content and sharing
What are the usergenerated
components (including
discussion forums,
blogs, videos, “likes”,
comments, ratings,
and reviews)? Which,
if any, social media is
used?
information is easy to
understand, but may not be
personalized enough to meet a
wide variety of users needs.
quick and ease record keeping.
written, but the design of the
application gets in the way of
its literacy.
There is very little usergenerated content and sharing
associated with this
application. This may have to
do with the sensitive nature of
the topic, and the desire to
protect a person’s anonymity.
With that said, users have
rated in the app store this
application with five stars, and
have wrote positive reviews
about the simple nature of the
applications design, and its
positive effect on aiding them
in their treatment process.
There is virtually no user
generated content, and very few
reviews/rating to gain an
understanding of the overall user
focused experience.
There is no identified usergenerated content, however
individuals can choose to share
their data with a friend for
support.
Social media also does not seem
to be used with this application.
Social media only seems to be
used to promote the
applications “brand” itself, but
does not seem to be being
used as a place to support and
generate a sense of
community.
The privacy policy is not explicit
and is also not listed on the
google play store download
page. It is unclear exactly what
the privacy policy is for this
application.
Yes, the privacy policy is well
spelled out on the website and
on the application itself.
Social media only seems to be
used to promote the
applications “brand” itself, but
does not seem to be being
used as a place to support and
generate a sense of
community.
Yes, the privacy policy is well
spelled out through the
supplemental website, and
there is also a link to it from
the application itself.
Policies
Are there explicit
privacy policies or
ones for how
information is used at
registration?
The application collects
personal information (such as
name, address, etc.) and uses a
privacy-protected pin to
ensure that users healthinformation is being protected,
however they also state that it
is the ultimate responsibility of
the user to ensure that their
password/pin is not
compromised.
The application collects
personal information (such as
name, address, etc.) and also
collected statistics based on
user health information that is
not identified to any specific
user.
Registration
Do users register and,
if so, what can they do
before and after
registering? What
information is tracked
or displayed?
Cost
Is there a cost for the
app or device? Are
there premier
features?
Users do not need to register
in order to use the application,
however they do need to
manually enter a personalized
pin if they would like a higher
level of security over their
health-information.
Users do not need to register in
order to access the application.
Once the user downloads then
can immediately begin to track
their food and can export or
delete all of their food logs.
Information that is tracked
refers to a persons personal
information such as: name,
address, email, etc.
Registration is free and the
user does not need to enter in
any information in order access
the application. Patients can
enter information into their
profile if they would like to,
however it is not required. In
order to sign online though it is
necessary to provide an email
address.
They collect personal
information such as name,
address, etc. User health
information is only collected
based on generalized statistics
There is no cost associated
with this app
There is no cost associated with
this app
There is no cost for this
application and no premier
features exist that would need
to be paid for
Devices and websites
Does the app or device
tie into any others
apps, devices, social
media, or websites?
Yes, the application connects
to a supplemental website in
addition to a facebook,
instagram, twitter, and tumblr
social media accounts. The
application also ties into the
ConnectED application
The application does not connect
to any supplemental website,
social media, or additional
application.
Yes, the application connects
to a supplemental website as
well as a helpline, and clinician
user based application.
Support and feedback
Is there a website or
support forum for
users? Is there a way
to provide feedback?
Is there a feedback
survey?
There is an area in the mobile
application where users can
suggest feedback. They also
can ask for app support via
email. There is no feedback
survey present for evaluation
purposes.
There is not a website for
support, or a forum when users
can go to voice there concerns.
The best place for this to take
place it appears would be in the
reviews section of google play.
There is an area in the mobile
application where users can
suggest feedback. They also
can ask for app support, and
there is a FAQ and general help
section for basic questions.
Description of Design
Balance – Design Description
The Balance mobile health application will be designed to act as a replacement tool for
traditional pen and paper self-monitoring assignments given to restrictive eating disorder
patients. These assignments traditionally require the individual to write down what they eat,
exercise, how they feel throughout their day, and any negative behaviors that may take place
such as binging, purging, restricting, over exercising, etc. The purpose of self-monitoring is to
allow for the individual to gain a better understanding over his or her own behaviors, and begin
to recognize triggers, and emotions surrounding food. Self-monitoring also allows for the
therapist and registered dietitian to better understand what is occurring during a patient’s week
in-between therapy sessions, and enables them to better guide the patient towards recovery.
While this all sounds very idealistic, the realistic nature of self-monitoring is that it ultimately is
just that…idealistic. When performed consistently self-monitoring can be incredibly beneficial to
a person’s overall recovery and treatment, however in most cases self-monitoring is very
difficult for an individual to maintain and comes with a high need for self-efficacy, which most
eating disorder patients beginning treatment do not necessarily possess.
Knowing these challenges that individuals face in traditional self-monitoring treatment, the
Balance mobile health application aims to decrease these barriers through a simplified selfmonitoring design format that will allow for quick, personalized, tracking of information.
Additionally, the Balance application will have a clinician user interface, which will allow
clinicians to seamlessly track their patients success throughout the week and be alarmed if their
patient seems to be struggling or may be in danger.
Color/Graphic Schema
In terms of visual appearances, the Balance mobile health application will be designed with a
clean, sleek look, that uses a variety of blues, greens, and yellow colors in order to remain
gender neutral. Rather than requiring individuals to manually type in all of their self-monitoring
information, which can seem overbearing, as well as create feelings of guilt, the application will
mostly utilize graphic images to state a specific behavior, or eating habit. For instance, if an
individual binged on two boxes of cereal all the individual has to do is double tap the cereal box
icon, rather than type out the she binged on two boxes of cereal. Similarly, in order to ensure
that accurate information is being recorded, and to reduce self-monitoring barriers, an
individual’s moods, and tracking of negative eating disorder behaviors (such as laxative use for
instance) will also be depicted with a simple graphic. For instance, a capital bolded L could
indicate that the person used a laxative, without the individual having to write out that he or
she took a laxative, which could elicit feeling of guilt, or a desire to not record the behavior.
Patient/Clinician Experience
Step One: Enrollment
When an individual initially opens the Balance mobile health application they will be asked to fill
out a series of password-protected questions in order to protect their privacy. Additionally, they
will be asked to sign a terms-of-agreement form, which allows for the Balance team to use de-
identified data in the further modification of the applications design, development, and overall
user functionality.
Note: An individual can choose to deny this form in which case their data will never
become accessible by the Balance development team.
Step Two: Clinician – Patient Connection
Next, the individual will be asked a series of questions in order to better understand where their
eating disorder falls, and how severe it may be. These questions will be based off of the
evidence-based DSM-IV tool for diagnosing eating disorders. At this time, the individual will also
be asked to choose their current primary care physician, therapist, and registered dietitians
from a list of clinicians organized by state.
Note: If the individual is not currently receiving personalized treatment, a team of
professionals will be recommended to them based on their questionnaire answers. If
the individual accepts this team of professionals, they will be immediately contacted
and will notify the individual within three-business days for the scheduling of initial
appointments. If an individual denies the recommended personalized treatment team,
they can choose another team manually or they can use the automated
recommendations of the application independently of a support team.
If an individual chooses to work with the application alone, they will be warned that
treatment and recovery is most effective when the application is used in conjunction
with face-to-face therapy. They will also be pointed to the 24-support hotline that is
available for all patients if they feel as though they may be in distress.
Step Three: Self-Monitoring
At this time the individual will now begin to self-monitor. On the main screen eight-bubbles will
be present with the days of the week listed, and one button that says, “weekly overview”. The
individual will click on the applicable day of the week which will then open a screen with eight
new buttons: breakfast, morning snack, lunch, afternoon snack, dinner, dessert, water, exercise.
Note: This screen can be customized to fit the individual’s needs, for example if they
only eat three meals a day, the snacks can be removed from the interface.
If the individual is currently receiving treatment from a registered dietitian their recommended
meal plan for the week will be automatically integrating into each day, and will appear in
graphic form. For instance if for breakfast an individual is recommended to have two eggs and a
piece of fruit, those images will appear when the person taps the breakfast circle. At this point
all the individual has to do is check that they consumed that food or ex-out the food if they did
not consume it. If they consumed multiple servings of a food all they have to do is tap the food
icon multiple times and each serving will be recorded. This will allow for individuals who binge
to record their binging without having to write out that they ate 10 granola bars, all they have to
do is tap the icon 10 times, which is viewed to present the individual with less guilt.
Individuals also have the ability to search a large inventory of foods (showcased in graphic form)
if the individual chooses to eat something that was not on their recommended plan. Recent
food items will automatically appear in the beginning of each search making the recording
process easier as the days/weeks goes along. Additionally, if the individual is not receiving
nutritional treatment, a recommended plan will automatically generate based on the persons
current health status, and eating disorder severity determined by the DSM-IV scale.
After each meal, an automatic mood graphic will pop up which will ask the individual to choose
an emotion that he or she felt after eating. Once again, the individual will tap the circle that best
fits his or her emotion. Next, a listing of negative eating disorder behaviors will pop up with
various symbols that represent restricting, taking laxatives, etc. and the person will be asked to
tap any behavior that may have taken place after consuming the meal.
Water will also be tracked similar to the way FitBit tracks water on a user friendly sliding scale,
and exercise will be automatically integrated using the smartphones GPS. For apple phones the
health application with sync with this aspect of the Balance application, however individuals will
not be able to see how many calories they burned, instead they will only be able to view where
they stand for their daily exercise based on their current plans recommendations.
Step Four: Weekly Overview
At the end of a week, the user will be able to see how well they self-monitored, in addition to
how many times they met their nutritional needs, and how many negative behaviors occurred
throughout a week.
Clinician Experience
The individuals support team will receive the patients daily information to their mobile
application user-face as well, and will be able to better treat the patient during face-to-face
counseling because they will already know how the person’s week went, and where they may be
struggling.
The clinician will be notified if the patient seems to be struggling during the week, and will be
alarmed if that patient seems to be in danger. They also will be able to track the patients
progress, mood, and determine how to edit the patients plan based on their level of recovery.
Application Features
1. 24 hour clinician support hotline
2. Push reminder notifications to eat, drink water, and self-monitor
3. Helpful alarms around times of day when a person may be more inclined to purge,
restrict, or use laxatives.
4. Customizable colors and fonts
5. Customizable meal recording interface
6. Multiple language options
7. Ability to enter in new foods and choose application graphics
8. Apple Health Application Syncing
9. ConnectED Syncing for Access to Local Eating Disorder Specialists
10. Clinician Focused Alarms (based on patient behaviors)
Evidence Based Compliance
Staying in line with evidence-based best practices, the very essence of the Balance application is
to allow for the treatment of restrictive eating disorders, through self-monitoring, one of the
foundations associated with popular Cognitive Based Therapy.14 The application also seeks to
remove any barriers, and stigma, and aims to allow for a quick, and guilt free patient experience.
By avoiding potential triggers associated with the proliferation of disordered eating, such as
extreme calorie counting, and exercise tracking, the Balance application uses current selfmonitoring best practices, and works them into less overwhelming digital format. The
application also does not aim to replace face-to-face therapy and is built to act as a
supplemental tool for the treatment of restrictive eating disorders, which is in alignment with
evidence based compliance, and professional recommendations.
Persona Usage
The Balance application would be useful for all of the identified personas, mostly because of the
streamlined user functionality, and the personalized nature of the mobile application. Also
because it has been specifically designed for individuals who suffer from restrictive eating
disorders, it does not include any targeting for individuals that may be overweight or obese from
binge eating disorder, and is focused on the kind of information and therapy that is needed for
those with restrictive tendencies, that may be supplemented with some binging. Even for those
individuals who are not open to really recovering from their eating disorder, the Balance
application is so easy to use that it still is something that a person would be willing to try, and at
least become more aware of their own habits, whether they are inclined to work on changing
them or not.
Improvement and Capitalization
The Balance application improves on existing applications by providing an application to a
targeted audience, in ways that other eating disorder applications have not in the past. The
Balance application is also rooted in evidence based guidelines, which gives it a greater sense of
authenticity for medical practice than some of the other applications that were designed
seemingly without the input of licensed professionals. The Balance application will capitalize on
the gap in the current marketplace that exists for helping individuals with restrictive eating
disorders, and provides a simple, seamless way of connecting practitioners and patients. More
so than other applications Balance is designed to be personalized, and streamlined. It has taken
some of the positive design elements from other applications, and made those elements more
user friendly, and less cumbersome. For instance, by allowing users to tap an image/graphic
rather than write in all of their information, the user is more likely to be honest and record what
actually happened, rather than choose not to record that they purged five times that day
because simply writing it down can cause intense feelings of shame and guilt.
Wireframes depicting a subset of the functionality
Evaluation Plan
Evaluation will take place during two distinct stages of the application design and development.
The first phase of evaluation will take place at the one-year mark of project design, and the
beginning of application development. At this point focus groups will be recruited with
recovered restrictive eating disorder patients. These focus groups will be conducted over a twomonth time period with the goal of determining how overall application design, and
functionality relates to a variety of restrictive eating disorders.
A series of key informant interviews will be conducted to better understand how to increase
user functionality, and maintain the highest level of efficiency in the management of treatment
through self-monitoring. These focus groups and interviews will take place over a two-month
time period. Website design, and mobile application modifications will take place post-focus
groups and interviews, which is anticipated to take an additional four months.
Focus groups and informational interviewers will analyze the application design based on a set
of criteria, which have been determined to be influential to the overall success of the
application.7 Based on their recommendations the mobile application will be modified to better
meet the needs of the target population. Ideally, after this phase the majority of design
modifications will have been made.
Box One: Focus Group and Informational Interview Key Areas of Evaluation
1. Visual Design – Members of the focus groups and individuals interviewed will be
asked to critique the overall design of the application, and provide feedback on font
choice, color schema, gender neutrality, image/graphic choices, etc. to determine
what aspects of the visual design need to be modified.
2. User Functionality – Members of the focus groups and individuals interviewed will
be asked to rate overall functionality, determine any barriers, issues that could turn
of a patient, and gaps in current function.
3. Ease of Usage – The level of ease of usage is at the center of this application, and will
be critical for its success. It should not take an individual more than 3 minutes to tap
through a meal, mood, and tracking of negative behavior.
4. Literacy – It is important the application instructions be written in a health literate
manner. Ideally the application should be written at a sixth grade reading level. Any
confusion in the instructions of the application needs to be identified in this early
evaluation stage.
5. Sensitively – Eating disorders are incredibly sensitive, and personal issues. Any issues
in sensitivity are of interest, and will be taken very seriously.
6. Motivation – The application needs to enforce self-efficacy if the person using the
application is going to continue to use it for an adequate period of time needed for
treatment.
7. Presence of any Restrictive Triggers – Any triggers than may have been overlooked
in the application ideally will be caught during this initial evaluation. The removal of
any restrictive triggers is incredibly important for the overall safety of this
application, and need to be determined before releasing to the pilot-audience.
8. Overall Application Satisfaction – It will be important for the Balance application
design and development team to understand overall satisfaction, and what areas of
the application could use modification to increase the users positive experience.
The second phase of evaluation will take place one year prior to the official launch of the
project. At this time a pilot program will take place with ideally 150 patients identified from
current psychiatric care providers. The pilot-phase of evaluation will take place over a threemonth time frame, allowing for sufficient time to pass for small behavior changes to be seen and
recorded in the application. Throughout the course of the pilot-phase, data will be collected
based on participate data, and surveys will be pushed to users in order to gain an understanding
of the overall user experience. Additionally, clinicians of the patients participating in the pilotphase will be provided with a survey in order to address their perception of the application,
where they believe functionality could change to make their user experience more positive, and
how they ultimately perceive it to be affecting the treatment process of their patients. Post-pilot
phase a three-month modification of the mobile application will take place based on data
collected throughout the course of the pilot-program. After this final modification the
application is expected to be ready to launch to the greater public.
Development plan including cost and schedule estimates
In order to ensure the maximum reach of the Balance application, the application will be
designed for user compatibility on both Apple iOS and Android Smartphones. Additionally, the
Balance application will be accessible on iPad and MacBook devices. There will also be a
supplemental website associated with the application that can be used as a stand alone tool
with access being possible through a series of password protected steps, or the website can be
used in sync with the application as an additional way of entering and accessing information.
The addition of a supplemental website will allow for patients to easily print, view, and enter
their information, however the website will not provide any additional information or resources
that the mobile application does not. The use of a website will simply be to allow for a wider
variety of personal preferences when using the Balance application. The Balance website will be
designed to be compatible with a wide variety of web-browsers such as: Google Chrome,
Internet Explorer, Mozilla Firefox, and Safari.
Content will continuously be edited and re-formatted to better suit the needs of our target
population with the help of a support staff of qualified consultants from the medical, nutrition,
and psychiatric fields. Additionally, an evaluation and advisory team will be put in place in order
to ensure that the application maintains a high level of user functionality, and efficiency. The
advisory and evaluation teams will meet quarterly in order to allow for continuous monitoring,
and development to occur.
Costs
Partnerships with applicable medical organizations will be considered to help fray the costs
associated with the design, development, implementation, evaluation, and continued
maintenance and support of the Balance application. Specifically, the National Eating Disorder
Association, as well as the American Medical Association, American Public Health Association,
and American Psychiatric Association will be targeted for collaboration. Additionally, Harvard
Medical School, and Tufts University School of Medicine, as well as other leading medical
schools throughout the country will be targeted for the identification of key consultants who will
be responsible for aiding in the medical, psychiatric, and nutritional development of the
application. It is anticipated that the costs to get the Balance application to market will be
entirely covered by investors, medical association partnerships, and university based support.
The Balance application will always be offered as a free application in order to ensure that there
is no barrier to the use and downloading of the mobile application.
Based on the proposed design, development, and implementation plan of the Balance
application, it is projected that the total cost of getting the application to market will be
upwards of $250,000. Please see table two below for the breakdown of costs associated with
getting the Balance application to market.
Table Two: Balance Application Costs
Elements
Project Manager (Salary)
Project Coordinator (Salary)
Website Designer (Contract)
Mobile Application Designer (Part-Time)
Technical Support (Part-Time)
Psychiatric Consulting (Contract)
Medical Consulting (Contract)
Nutritional Consulting (Contract)
Marketing + Social Media
Evaluation
Total
Cost
$65,000
$35,000
$10,000
$30,000
$15,000
$30,000
$30,000
$20,000
$10,000
$10,000
$255,000
Scheduling
It is anticipated that the design and development of the Balance application will take a full two
and a half years (30 months) before the application can be released into the mobile health
marketplace. Initial conceptualization and drawing together of the medical consultant team who
will be involved in the development of the application will take roughly 3-4 months. During this
time a website and mobile application designer will also be identified in addition to a project
coordinator and project manager. Once the Balance application team has been determined,
design and development conceptualization and primary coding will begin and is anticipated to
take an additional 6-8 months.
At the one-year mark of project development, focus groups with recovered restrictive eating
disorder patients will begin to take place. A series of key informant interviews will be conducted
to better understand how to increase user functionality, and maintain the highest level of
efficiency in the management of treatment through self-monitoring. These focus groups and
interviews will take place over a two-month time period. Website design, and mobile application
modifications will take place post-focus groups and interviews, which is anticipated to take an
additional four months.
One year prior to the official launch of the project a pilot program will take place with ideally
150 patients identified from current psychiatric care providers. The pilot-phase of the
application will take place over a three-month time frame, allowing for sufficient time to pass
for small behavior changes to be seen and recorded in the application. Post-pilot phase a three
month modification of the mobile application will take place based on data collected throughout
the course of the pilot-program.
Six-months prior to the official launch of the Balance mobile health application various
marketing initiatives will begin to take place, which can be seen in further detail below in table
three. During this time the website will be launched, and marketing materials will be developed
for distribution. Final modifications of the mobile application and testing of user functionality,
and compatibility across all mobile platforms and Internet platforms will be tested.
Marketing plan
Three months leading up to the launch of the Balance application, marketing strategies will
begin to take place in order to increase word of mouth around the upcoming application.
Specifically, the projects key medical consultants will be assigned to give a series of
promotional/information talks at medical campuses, hospitals, medical association conferences,
and TED talks in order to begin to get the medical community talking about the application and
its proposed benefits for patients suffering from restrictive eating disorders. Initially it is
anticipated that medical professionals will be the primary resource for distributing this
application to the public.
Additionally, a college campus marketing initiative will be designed that will focus on reaching
campus counseling offices. With high rates of eating disorders existing on college campuses,
promotional flyers will be designed for the application, and will be distributed to college
campuses with the purpose of being distributed to incoming students at the beginning of the
school year. This is one planned approach for reaching a portion of the target audience that
could benefit from the Balance application, but may not currently be seeking any sort of
treatment where they would be referring to the application specifically.
Lastly, social media advertising campaigns will be planned during the first three-months of the
applications launch into the mobile health marketplace. During this time Facebook
advertisements will run daily, and promotional images, and statistics will run on Twitter and
Instagram. Because eating disorders are highly stigmatized, and individuals tend to hide their
condition as much as possible, it is important to advertise on social media platforms in a way
that provides reassurance to the patient that no one in the social media circle will be notified of
their interest or participation in the Balance application.
Table Three: Balance Mobile Health Application Marketing Timeline
Jun
Jul
Aug
App Launch
Sept
Oct
Medical Focused Talks
Campus Based Initiatives
Social Media Campaigns
Limitations
The limitations of this mobile application proposal mostly are associated with the current lack of
evidence, data, and overall research in the use of mobile-based health applications for the
successful treatment of patients with restrictive eating disorders.9 12 In general, mobile health
applications have actually been shown to have a negative effect on the recovery and treatment
of individuals with eating disorders, as individuals are required to constantly resist applications
that in many ways facilitate the habits that make up their own restrictive eating disorder
diseases.12
Nov
Additionally, when looking at the mobile health applications that currently do aim to address
eating disorder behaviors, very few focus on restrictive behavior, with the majority focusing on
binge eating disorder, and overall mental health status such as mood, self-worth, anxiety, and
depression.9 While all of these topics are worth addressing through the use of a mobile health
application, there is a clear gap in the marketplace that addresses extreme restrictive disorders.
It is also not believed that recovery and treatment can exist solely in a virtual space. Because
eating disorders are complex mental and behavioral disorder they require the integration of a
live support team who can monitor a patient’s recovery, and use a mobile health application
more as a means of reinforcing treatment between therapy sessions.15
With many applications promoting “thin-inspiration” currently the number of negative mobile
applications available for download by a patient with an eating disorder far outweigh the
positive. From my competitive analysis it was determined that there really currently are only
two applications that have the potential for aiding eating disorder patients through selfmonitoring based treatment.15 This limited our overall ability to use current similar mobile
applications successes and failures to further support the design and development of the
Balance application.
Lastly, because eating disorders are very personalized conditions, with no one person’s disorder
being exactly the same to another person’s, there are some expected limitation to the level of
personalization that will be capable of being achieved in this mobile application platform. While
it is anticipated that as users use the application and provide feedback, the level of design
modification and personalization options will improve, it can be expected that this application
may never have the ability to provide the same level of personalized immediate treatment that
is capable of existing in a face-to-face therapy session. While this is a limitation in the
applications overall functionality, it also is a reminder as to the place in therapy where this
application should exist. By no means should this application replace in-person therapy and is
meant to be used as a supplemental means of allowing patients to self-monitor in a more
comfortable, user friendly manner, that increasing their chances of success and the overall
experience they are capable of having during their in-person therapy sessions.
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About the author
Megan Faletra is a MS candidate at the Tufts University,
Friedman School of Nutrition Science and Policy
(concentrating in Food Policy and Applied Nutrition), and a
MPH candidate at the Tufts University School of Medicine
(concentrating in Global Health). She is also a Didactic
Program in Dietetics (DPD) graduate of Simmons College, and
will be beginning her dietetic residency at Brigham and
Women’s Hospital in August where she will earn credentials
required to become a Registered Dietitian.
Previously, she earned her Bachelor’s degree in Marketing
Communications from Loyola University in Maryland (2010),
with a Specialization in Italian Language and Culture. She then
went on to complete one-year of Clinical Nutrition Dietetic
Post-Baccalaureate education. During this time she worked as
a Health Promotion Consultant for National Financial Partners,
bringing obesity prevention, smoking cessation, and nutrition
awareness programs to corporate settings across New
England.
Prior, she had experience in both domestic & international
settings within varying community populations. She gained
international health advocacy and nutrition experience
through experience working in refugee camps in the Middle
East and rural communities in Central America, with focuses in
Nutrition Awareness, Malnutrition, Food Culture and
Community Outreach.