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Behavior Therapy 47 (2016) 325 – 338
www.elsevier.com/locate/bt

Motivational Text Message Intervention for Eating Disorders: A

Single-Case Alternating Treatment Design Using Ecological
Momentary Assessment
Rebecca M. Shingleton
Elizabeth M. Pratt
Boston University
Bernard Gorman
Derner Institute of Advanced Psychological Studies, Adelphi University
David H. Barlow
Tibor P. Palfai
Heather Thompson-Brenner
Boston University

receiving text messages, RMQ precontemplation scores

This study tested a motivational text message treatment
adjunct for individuals with eating disorders (EDs) who
exhibited high dietary restraint/restriction. Method: A
replicated single-case alternating treatment design was used
to examine (a) the feasibility of combining a brief motivational
interview with subsequent text messages and (b) the influence
of the text messages on eating behaviors and motivation to
change in individuals with EDs (N = 12). The protocol was
8 weeks and the text messages were adjunctive to cognitive-
behavioral therapy. Results: The intervention was well
accepted (mean rating = 7/10) and feasible within the context
of monetary compensation (mean daily monitoring compliance
=91%). Text messages did not impact behavioral outcomes:
dietary restraint and kilocalorie intake. They had mixed effects
on motivation to change dietary restraint, measured by the
Readiness and Motivation Questionnaire (RMQ). When
This study was supported by grants F31MH097308 (RMS) and
K23MH071641 (HTB) from the National Institutes of Health/
National Institute of Mental Health (NIMH). The research was
conducted at Boston University.
Address correspondence to Rebecca Shingleton, M.A.,
Boston University, 648 Beacon Street, Boston, MA 02215;
e-mail: rshingleton@gmail.com.
0005-7894/© 2016 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
(desire to restrict) significantly increased, indicating decreased
motivation; however, action scores (effort toward reducing
dietary restraint) significantly increased, indicating increased
motivation. These effects were moderated by weight status.
Underweight individuals (n = 4; body mass index [BMI] b
19.0) reported increased ambivalence—that is, an increased
desire to restrict and increased action toward reducing
restriction—in response to the text messages. Normal weight
participants (n = 8; BMI N 19.0) reported only increased
action toward reducing restriction in response to the text
messages. Discussion: These data demonstrate text messages
are a potentially feasible and acceptable treatment adjunct and
may be effective at increasing motivation to change for normal
weight individuals, while their influence on underweight
patients is more complex. These findings provide a founda-
tion for future research in technology-based motivational
interventions for EDs and offer preliminary evidence for using
these methods among normal weight individuals.
Keywords: eating disorders; motivation; text message; technology
OUTPATIENT PSYCHOLOGICAL TREATMENTS FOR eating
disorders (EDs), including anorexia nervosa (AN)
and bulimia nervosa (BN), require further research
326 shingleton et al.
attention. Cognitive-behavioral-based treatments
are considered the first line of psychological care
for BN (National Institute for Health and Care
Excellence, 2011); however, remission rates typically
fall between 40 and 60% in treatment trials (Agras,
Walsh, Fairburn, Wilson, & Kraemer, 2000; Keel &
Mitchell, 1997). In AN, there is evidence that
cognitive-behavioral therapy (CBT) may reduce ED
behaviors, assist with weight gain, and reduce relapse
(Fairburn et al., 2013; Pike, Walsh, Vitousek,
Wilson, & Bauer, 2003). But overall, outpatient
treatments for adults with AN demonstrate weak
effects (Bulik, Berkman, Brownley, Sedway, & Lohr,
2007). The research to date indicates that novel
treatments and treatment adjuncts are needed to
improve outcomes across EDs.
A number of studies have shown that treatment
outcome is negatively impacted by high levels of
dietary restriction, defined as deliberately limited food
intake, and dietary restraint, defined as attempts to
limit food intake or follow rules regarding food
choices (Fairburn, 2008). In BN, high posttreatment
dietary restraint predicts relapse (Halmi et al., 2002)
and reducing dietary restraint early in therapy
mediates treatment response (Wilson, Fairburn,
Agras, Walsh, & Kraemer, 2002). In AN, increasing
dietary variety and density, two components related
to caloric restriction, predict long-term outcome
(Schebendach et al., 2008). Additionally, persistent
caloric restriction is likely linked to relapse (Walsh,
2013) and degree of restriction is a marker of clinical
severity (De Young et al., 2013). While reducing
restriction is critical to symptom remission, individ-
uals with EDs exhibit low motivation to change
dietary restraint (Ackard, Cronemeyer, & Egan,
2015).
Low motivation to change is posited to play a key
role in maintaining EDs (Vitousek, Watson, &
Wilson, 1997) and is associated with poor treatment
outcome (Clausen, Lubeck, & Jones, 2013). More
specifically, motivation to change dietary restriction
has been shown to be a stronger predictor of treatment
outcome than motivation to change other ED
symptoms (ED cognitions, bingeing, purging; Geller,
Drab-Hudson, Whisenhunt, & Srikameswaran,
2004). Unfortunately, individuals with AN and BN
are more resistant to changing restriction than
changing other symptoms (Ackard et al., 2015).
This is likely due to the egosyntonic nature of
restriction (Vitousek et al., 1997) and the congruence
between caloric restraint and ED patients’ overall
desire to change their body, shape, and weight
(Fairburn, 2008)—that is, dietary restriction and
restraint align with the core eating disordered goal
to lose weight and change one’s shape. Because these
individuals place high importance on their body
image, they want to restrict in order to work toward
their ideal shape/weight. Restriction and shape/weight
concerns together fuel the ED and perpetuate this
problematic cycle. Minimal research has focused on
motivation enhancement targeting dietary restriction/
restraint, and innovative research is needed to target
this recalcitrant symptom.
Researchers have applied motivational interviewing
(MI) to address the low motivation that is often
exhibited in ED populations. The data suggest that MI
may have a positive impact on treatment-related
variables such as motivation to change, engagement,
and dropout (e.g., Dean, Touyz, Rieger, & Thornton,
2008; Weiss, Mills, Westra, & Carter, 2013). This
research is encouraging, but recent reviews indicate
that while MI and related techniques may impact
variables such as treatment engagement, there is
limited evidence that MI directly reduces ED
behaviors, particularly dietary restriction (Knowles,
Anokhina, & Serpell, 2013).
More potent forms of motivational enhancement
may be needed to support change in core ED
behaviors beyond MI-based interventions delivered
in the traditional face-to-face (FTF) format with a
limited number of sessions (i.e., one to four sessions)
as seen in the protocols to date. Technology-
delivered ecological momentary interventions
(EMIs), which are delivered throughout day-to-day
activities within the natural environment, may be one
way to extend motivational interventions beyond a
time-limited FTF format. The benefits of EMI include
the ability to extend therapeutic interventions
beyond the therapy session and generalize therapeu-
tic lessons to the real world (Heron & Smyth, 2010),
and may be well suited to the fluctuating nature of
motivation (Waller, 2012).
Researchers have recently utilized new technolo-
gies as tools for ecological momentary assessment
(EMA; assessment collected in real time and in the
natural setting) and EMIs. One form of EMI is the
use of text messaging via mobile phones. A number
of studies have demonstrated the effectiveness of text
messages to promote positive changes such as weight
loss, smoking cessation, and adherence to antiretro-
viral medications (Hall, Cole-Lewis, & Berhnardt,
2015). While text messages have shown to be helpful
in other domains, only a handful of studies have
investigated their utility for EDs. Two of the three
studies using text messages have found generally
positive outcomes. Specifically, Bauer, Okon, and
Meermann (2012) used text messages that provided
feedback on participants’ current symptomatology
as an aftercare program for individuals with BN who
were discharged from an inpatient hospitalization.
Those who received the messages were more likely
to achieve and/or sustain remission from bingeing/
 text message intervention for eating disorders
purging compared with the control group. Shapiro
et al. (2010) reported high rates of compliance with
text messages monitoring binge/purge behavior
during CBT for BN in a sample of N = 31. They
also noted generally positive ratings concerning the
feedback text messages that encouraged and advised
participants on their reported symptoms. In contrast,
patients in a third study preferred in-person care
(Robinson et al., 2006). No study has investigated
text messages in AN samples, though one group of
researchers piloted a “vodcast” (i.e., mobile video)
encouraging patients with AN to consume food.
These researchers found better results in experimental
food consumption in an outpatient setting as
compared with the inpatient setting (Treasure,
Macare, Mentxaka, & Harrison, 2010; Cardi,
Lounes, Kan, & Treasure, 2013). The current study
is the first study to use text messages as an ecological
motivational tool to enhance motivation and reduce
dietary restriction/restraint.
Our aim was to test a motivational text message
treatment adjunct for individuals with EDs who
exhibited high dietary restriction/restraint in a repli-
cated single-case alternating treatment design (ATD).
Within ATDs, two phases of differing interventions
are semirandomly administered multiple times within
subjects, and data are collected across all phases
(Barlow, Nock, & Hersen, 2009). This design controls
for sequencing effects while maintaining high internal
validity. This method is an elegant way to test the
impact of an intervention on outcomes that are
repeatedly measured in a small sample size. Our
goal was to investigate if motivational text messages
are acceptable and feasible as a CBT adjunct and if
they result in increased kilocalorie intake, decreased
dietary restraint, and increased motivation to change.
We hypothesized that (a) the text message intervention
would be well received and feasible as assessed by
compliance with daily monitoring and an acceptabil-
ity questionnaire; and (b) the intervention text
message phases would be associated with increased
kilocalorie intake, reduced dietary restraint, and
higher motivation to change.
Methods and Materials
participants
Adults (age range 18–26 years old) with AN,
subclinical AN, and BN with high dietary restraint/
restriction using DSM-5 criteria were enrolled in the
study. All participants were at least 18 years old, had
a body mass index (BMI) of 16.5 kg/m 2 –25.0 kg/m 2
(i.e., under- to normal weight), and obtained medical
clearance from their medical provider or Center for
Anxiety and Related Disorders (CARD)-affiliated
doctor. The individuals whose BMI was between
19.0 and 25.0 were classified as “normal weight” and
327
exhibited clinical levels of dietary restraint or restric-
tion defined as a score of 3.2 or higher on the Eating
Disorder Examination (EDE; Fairburn, Cooper, &
O’Connor, 2008) and/or self-reported kilocalorie
intake b 1200/day. Individuals who had a BMI of
b 19.0 were classified as “underweight.” Two partic-
ipants were diagnosed with generalized anxiety
disorder, n = 1 was diagnosed with social anxiety
disorder, n = 1 met criteria for obsessive–compulsive
disorder, and n = 1 met criteria for panic disorder.
Only one participant was in concurrent psychological
treatment for non-ED symptoms. Exclusion criteria
were current/recent suicidal risk; comorbid substance
abuse/dependence, bipolar disorder, schizophrenia, or
mental retardation; and concurrent psychotherapy
focused on their ED outside of the treatment at
CARD. Patients receiving psychopharmacological
treatment were included if medications were stable
for at least 6 weeks. See Figure 1 for a CONSORT
diagram of participants.
procedures
All study procedures were conducted at the CARD
Eating Disorder Program and were approved by
the Boston University Institutional Review Board.
Participants were recruited via community and online
postings and clinician referrals between October
2013 and November 2014. All individuals who
called CARD and expressed interest in the study were
screened for potential eligibility via a brief phone
screen. The phone screen included questions regard-
ing demographics; self-reported height and weight;
ED symptoms; and other psychological symptoms
such as depression, suicidal ideation, psychosis, and
substance use. Informed consent was obtained at the
in-person screen during which semistructured inter-
views were conducted to ensure eligibility and
describe the sample. Height and weight were collected
by the clinician at the in-person screen and used to
calculate BMI.
Upon confirmed eligibility and medical clearance,
the individuals completed a battery of self-report
questionnaires and completed a single MI session
with the first author (R.M.S.). The MI session was
conducted FTF and lasted approximately 1 hour.
R.M.S. then created approximately 60 individualized
text messages for each participant that were sent prior
to meal times. 1 While mealtimes may have varied
from day to day, the timing of the messages was
collaboratively set with R.M.S. and the participant.
1
It took approximately 45–60 minutes to develop the persona-
lized messages for each participant. This time decreased over time
as a bank of text messages was created over the course of the study.
Because common themes arose during the MI sessions, some text
messages were shared across participants.
328 shingleton et al.
Phone screened for eligibility
N = 77
In-person screened
N = 26
Eligible N = 20
Enrolled N = 13
Completed N = 12
FIGURE 1
Together they identified a consistent time that would
best capture when the participant could read the
messages before meals. Across all phases, participants
received a nightly text message reminder to complete
their questionnaire and food logs. This reminder
message was sent prior to bedtime and did not include
any motivational components. Two days after the MI
interview, the participants began completing the
nightly questionnaire on their smartphone via the
SymTrend application.
Each participant underwent a semirandomized
sequence of text message and no text message phases.
The phases were 1 week in duration and summed to
4 weeks of receiving text messages and 4 weeks of
not receiving text messages. The primary outcomes
(dietary restraint, restriction, and motivation) were
collected daily across all phases. Over the course of
the 8 weeks, participants also received outpatient
CBT for their ED at no cost with a clinician from the
Center. At the end of the 8-week protocol, partici-
pants completed termination self-report measures
and completed an acceptability questionnaire and
brief feedback session. They were compensated $100
for participating in the study and received a $50
bonus if their compliance rate with the nightly
questionnaire and food logs was above 80%.
Not eligible per ED ( n = 4)
BMI too high (n = 1)
Did not fit clinical profile for
statistical analyses ( n = 1)
Lost to follow -up ( n = 5)
Unable to commit to study
time requirements ( n = 2)
Withdrawn n = 1
Patient CONSORT diagram.
randomization of text message/no text
message phases
Randomization was determined using a computer
program, but was semirandom in nature such that the
phases were rerandomized until adequate alternation
was achieved to compare interventions. For example,
if a randomization outcome was 4 weeks of text
messages followed by 4 weeks of no text messages,
the phases would not be alternating. In such a case
(i.e., an AB design), the authors would not be able to
draw conclusions regarding whether or not the
outcomes were impacted by the administration and
withdrawal of the intervention being tested. There-
fore, the order of phases was rerandomized using the
computer program until the appropriate alternation
necessary for ATD data analysis was obtained.
intervention
The first phase of the intervention was the FTF MI
session. The aim of the MI session was to help the
participants articulate why they wanted to overcome
their ED. During this session, the therapist used
MI-based techniques such as open-ended questions
and reflections and focused on MI components such
as supporting autonomy, rolling with resistance, and
expressing empathy. Because participants often did
 text message intervention for eating disorders
not link their ED symptoms (e.g., bingeing, weight
loss) to caloric restraint, participants were provided
psychoeducation regarding the cycle of ED thoughts
and behaviors, specifically that shape/weight concern
leads to dietary restraint that in turn leads to either
underweight status and/or binge/purge behavior
(Fairburn, 2008). This conceptualization provided
a rationale for reducing dietary restraint as a primary
treatment target. The psychoeducation was delivered
using MI techniques such as those discussed above.
The personalized motivational text messages were
then developed from content discussed during each
individual’s pretreatment MI session. The text mes-
sages reflected domains discussed by the participants
that were negatively impacted by the ED (e.g., rela-
tionships, work, school, physical health). The mes-
sages were written in “text message format” (i.e.,
short and colloquial) and were sent prior to when the
participants reported typically having meals. The
messages were designed as an adjunct to CBT for
EDs that focused on regular eating and reducing ED-
related cognitions. In order to align with the CBT
principles (Fairburn, 2008), the messages addressed
the patients’ restrictive eating behaviors and associat-
ed consequences. Some sample text messages were
“Increasing daily calories will help you break the
vicious ED cycle and will help you move forward!”
and “Eating more is good for your emotional and
physical health.”
Over the course of the 8-week text message
intervention, individuals also received outpatient
treatment for their ED based on the gold-standard
CBT enhanced for EDs (Fairburn, 2008) by advanced
graduate students supervised by ED clinical experts.
The treatment sessions were focused on regular
eating and associated ED behaviors and cognitions
(e.g., in-session weigh-ins, shape/weight concerns).
measures
Eating Disorder Examination (EDE)
The EDE (Fairburn et al., 2008) is considered the
gold-standard interview for comprehensively asses-
sing eating behavior and cognition. It consists of a
global score and four subscale scores: dietary restraint,
shape concerns, weight concerns, and eating concerns.
The scores are based on a 6-point scale with 0
indicating no pathology and 6 indicating severe
pathology. Research has indicated good reliability
and validity across EDs (Cooper, Cooper & Fairburn,
1989). It was administered at baseline to determine
eligibility and describe the sample.
Structured Clinical Interview for Axis I DSM-IV
Disorders (SCID-I)
The SCID-I (First, Spitzer, Gibbon, & Williams, 2002)
is a semistructured interview used to diagnose Axis I
329
pathology, is commonly used in ED treatment trials
(e.g., Agras et al., 2000), and has demonstrated
adequate reliability (Zanarini & Frankenburg, 2001)
and diagnostic validity (Basco et al., 2000). The
SCID-I was administered at baseline to determine
eligibility and describe the sample.
Readiness and Motivation Questionnaire (RMQ)
The 64-item RMQ (Geller, Brown, Srikameswaran,
Piper, & Dunn, 2013) assesses motivation to
change eating disorder-related cognitions and
behavior across ED diagnostic categories. For
each of four ED symptoms: restraint, bingeing,
ED cognitions, and compensatory behaviors, this
questionnaire measures precontemplation (i.e.,
desire to engage in ED behaviors), action (i.e.,
actions toward reducing ED behaviors), internality
(i.e., changing for self vs. others), and confidence
(i.e., confidence in ability to reduce ED symptoms).
These subscales have demonstrated good reliability
and validity across AN and BN diagnoses (Geller
et al., 2013). The subscale scores are percentages
(e.g., “How much of you has wanted to restrict
your eating?” followed by a 0–100 percentage
scale) and are designed to assess motivation over
the past 2 weeks. The complete questionnaire was
administered pre- and posttreatment. Additionally,
the dietary restraint subscale motivation scores
were adapted to be smartphone compatible and
were administered daily via the SymTrend applica-
tion on the participants’ smartphones. The adapted
questions asked “In the past day” as opposed to “In
the past 2 weeks” to reflect daily changes in
motivation. The subscale alpha scores of the
adapted version ranged from 0.95 to 0.98.
Eating Disorder Examination Questionnaire
(EDE-Q)
The EDE-Q (Fairburn & Beglin, 2008) is a self-
report version of the EDE interview and has
demonstrated good validity and reliability across
EDs (Peterson et al., 2007; Wolk, Loeb, & Walsh,
2005). The complete questionnaire was adminis-
tered at baseline and posttreatment and a modified
dietary restraint subscale was administered daily
via the SymTrend application on the participants’
smartphones. The modified format was used
because the original form asks individuals how
many days in the past month they engaged in ED
behaviors. We modified the questions to query if
they had restricted in the past day (e.g., “Have you
been trying to limit the amount of food you eat to
influence your shape/weight [whether or not you
succeeded]?” yes/no). This adapted scale was
scored as a percentage of questions answered
“yes.” The Cronbach’s alpha for the adapted
scale was .80.
330 shingleton et al.
Daily Food Records
Participants recorded their daily kilocalorie intake via
food logs. Participants were instructed to complete
the food logs in real time as opposed to the end of the
day, as in accordance with CBT methods. Data from
the food record were entered into the computerized
ESHA Food Processor (ESHA Research Inc., 2010), a
state-of-the-art nutrition software program, to obtain
their daily kilocalorie intake.
Medical Safety Questions
A brief self-report questionnaire assessed the primary
medical symptoms related to eating disorders, suicidal
ideation, and one open-ended item (“Have you had
any other physical symptoms?”). This measure was
administered at the initial intake and collected daily
on the smartphone to ensure medical safety.
Acceptability Measure
A simple acceptability questionnaire from a previous
text message study in ED patients (Shapiro et al.,
2010) was adapted for use in the current study. It
included five Likert-scale questions: (a) “How much
did the intervention meet your expectations?” (b)
“How likely would you be to recommend this inter-
vention to a friend?” (c) “How likely would you be to
participate in this intervention again if necessary?” (d)
“How much did you enjoy the self-monitoring
forms?” (e) “How much did you enjoy using the text
messaging program?”; and three open-response ques-
tions: (a) “What would you change about interven-
tion?” (b) “What did you like/dislike?” (c) “Any
further comments?” The scale ranged from 1 (not at
all) to 10 (extremely). It was completed posttreatment.
statistical analyses
Multilevel analyses (i.e., generalized estimating
equations [GEE]; Liang & Zeger, 1986; Zeger &
Liang, 1986) were employed to complement visual
analyses regarding the text message effect on the
dependent variables (kilocalorie intake, dietary re-
straint, and motivation to change) across participants
over time while accounting for BMI as a covariate.
Exploratory analyses investigating the interaction
effect of weight status (under- vs. normal weight) and
text messages on primary outcomes were also
conducted using GEEs. GEEs are particularly well
suited to longitudinal data in which the times of
observations differ between individuals (Snijders &
Bosker, 1993), which is necessary given the different
series of interventions participants received. These
analyses examined the differences between data
collected on days text messages were received versus
days no text messages were received within the
individuals. Missing data were not imputed because
GEE uses maximum likelihood estimation; therefore,
there is little or no need for imputation.
Sample size estimates for designs that have no
repeated measures have to take into account three
parameters: desired power, significance level, and
effect size. Additionally, repeated measures designs
have to account for the number of repeated measures
per individual and the intraclass correlation within
each cluster. Using the formula provided by Hedeker,
Gibbons, and Waternaux (1999); the Optimal Design
Software program (Raudenbush et al., 2011); and
given .80 power, .05 significance level, a moderate
(r = .30) effect size, 56 repeated measures per subject,
and an intraclass correlation coefficient [ICC] of .3,
the required number of subjects was estimated to
be 26 for a moderate effect and 11 for a large effect
(r = .5). Using the l mm power function in the R
package Longpower (Donohue & Edlund, 2013),
and setting the power to .50, the minimum sample
size for a statistically significant effect at the .05 level
would be 6. Therefore, although somewhat small
from a standard randomized clinical trial (RCT)
perspective, the present sample size of 12 seemed
plausible for this design.
Results
baseline characteristics
Twelve of the 13 participants who enrolled completed
the protocol (92.2% retention rate). Of these 12, the
majority of the sample was female (n = 10, 83%) and
Caucasian (n = 8, 67%). The mean age was 21.5
(SD = 2.35) years old. Four participants were diag-
nosed with AN, n = 4 were diagnosed with subclinical
AN, and n = 4 were diagnosed with BN with high-
caloric restriction/dietary restraint. Of those who were
diagnosed with AN, one individual was binge/purge
subtype. The sample mean BMI = 20.0 kg/m 2 (SD =
2.9; range: 17.1–23.4). See Table 1 for baseline dietary
restraint and motivation scores.
postintervention outcomes
The participants’ EDE-Q dietary restraint subscale
scores reduced significantly over the course of the
8-week intervention (i.e., CBT + motivational text
message adjunct). Additionally, precontemplation
scores decreased and action and confidence subscale
scores increased significantly from baseline to
postintervention. These changes indicate an increase
in motivation to change dietary restraint. The
internality subscale score did not significantly change
from baseline to postintervention. These data repre-
sent changes across the intervention as a whole, not
specific to the text message adjunct. See Table 1 for
postoutcome data.
Feasibility and Acceptability of the Intervention
On average, participants completed 91.5% (i.e., 51
out of 56 days) of the daily entries on SymTrend
 text message intervention for eating disorders 331

Table 1
Pre–Post Outcomes (N = 12) a
Measure Preintervention Postintervention tb p-value % change
M(SD) M(SD) M(SD)
EDE-Q Dietary Restraint 4.13 (0.75) 1.73 (1.51) − 6.13 .001 N/A
RMQ-Precontemplation 76.67 (21.88) 37.67 (24.44) 4.26 .001 − 39.83 (32.15)
RMQ-Action 30.42 (33.20) 73.75 (28.13) − 6.08 b .001 43.33 (24.71)
RMQ-Internal 62.08 (31.44) 74.17 (19.17) − 1.16 .270 12.08 (36.02)
RMQ-Confidence 54.17 (28.67) 75.83 (21.41) − 2.25 .046 21.67 (33.39)
Note. EDE-Q = Eating Disorder Examination–Questionnaire; RMQ = Readiness and Motivation Questionnaire–Dietary restraint subscale.
a
These data reflect overall changes from baseline to termination and do not speak to the specific contribution of text messages as an
adjunct to CBT.
b
Paired sample T test.

and 87.4% of the daily food logs, confirming our
hypothesis that the intervention would be feasible.
The participants found the overall intervention to be
acceptable (M = 7.05 out of 10 points, SD = 2.36),
confirming our hypothesis that the intervention
would be well accepted. The participants rated the
intervention as a whole, and the text messages
specifically, above average, and the only mean
below a score of 6 pertained to self-monitoring.
The scores for each question were as follows: (a)
“How much did the intervention meet your expec-
tations?” (M = 7.75, SD = 2.09), (b) “How likely
would you be to recommend this intervention to a
friend?” (M = 7.92, SD = 2.53), (c) “How likely
would you be to participate in this intervention again
if necessary?” (M = 8.00, SD = 2.89), (d) “How
much did you enjoy the self-monitoring forms?”
(M = 5.25, SD = 2.26), and (e) “How much did you
enjoy using the text messaging program?” (M = 6.33,
SD = 3.11). See Table 2 for sample positive and
negative feedback from the feedback questionnaire
and interview.
Text Message Effect on Kilocalorie Intake and
Dietary Restraint
GEE analyses indicated no significant main effects of
the text messages on self-reported kilocalorie intake
(Wald chi-square = 1.19, SE = −448.21, p = .28) or
dietary restraint (operationalized as percentage of
EDE-Q questions answered “yes”; Wald chi-square =
1.14, SE = 27.31, p = .29) when covarying for
baseline BMI.
Text Message Effect on Motivation to Change
Dietary Restraint
A significant main effect of the text messages was
found on the precontemplation scores to change the

Table 2
Feedback Regarding Text Message Iintervention
Positive Feedback
• Initially the text messages had a lot of impact on me.
Particularly when they used my own words because I felt like it
was the healthy voice inside of me that was communicating with
me by text.
• Logs helped with accountability.
• I liked the regular text check-ins.
• [Monitoring] offered time to reflect on the day.
• [I] liked the content... very specific to me.
• The [text messages] were understanding, not judgmental or
saying [change] was easy.
• I really liked getting the text messages that were personalized
to my individual goal.
• [The texts] made me think twice.
• [The texts were] a helpful little motivator.
• I liked the text messages. It makes you want to get better.
And it’s a voice against your eating thoughts.
• [The texts] gave me more strength.
• Getting the texts at mealtimes was really helpful and made
sticking to regular eating much easier.
Negative Feedback
• [The text messages were] not really helpful.
• I wish the recipient had a real name.
• I [wish I] could text, then get the text in that time of need.
• I didn’t like the SymTrend questions every night because it
wasn’t helpful.
• The texts seemed somewhat intrusive because of their
specifically relating to what we talked about in session.
• It would have been nice to have a question/entry about
feelings/triggers for binges/purges that have happened.
• I disliked the text messages, I didn’t find them that helpful.
They’re kind of like “no duh” comments that I’ll get from people
and it just makes me say that yes, obviously I know that.
• “Reminder from SymTrend” was a little distracting.
332 shingleton et al.
dietary restraint counter to the hypothesized direction
(Wald chi-square = 17.64, SE = − 18.96, p b .001).
When receiving text messages, individuals’ precon-
templation scores, which represent how much a
participant wanted to restrict, decreased less over time
compared with when they were not receiving text
messages for the entire sample. The change over time
during text message phases was approximately 10%
(60–50% desire to engage in restriction), whereas the
change over time during no text message phases was
approximately 20% (65–45% desire to engage in
restriction). These changes also illustrated that the
text messages were slightly more effective at the
beginning of treatment, whereas not receiving text
messages was slightly more effective at the end of
treatment (see Figure 2a).
A significant main effect of the text messages was
found on dietary restraint action scores, which
represent how much a participant was working on
not restricting, in the hypothesized direction (Wald
chi-square = 14.85, SE = 21.16, p b .001). Action
scores increased when participants received text
messages over time, whereas action scores remained
more stable when they did not receive text messages
over time (see Figure 3a).
No text message effects were found on internality
(Wald chi-square = 0.46, SE = 18.35, p = .51) or
confidence scores (Wald chi-square = 0.21, SE =
− 4.61, p = .64).
Exploratory analyses indicated a significant inter-
action effect between text messages and baseline BMI
on precontemplation scores (Wald chi-square =
11.65, SE = 0.28, p = .001) and on action scores
(Wald chi-square = 14.95, SE = 2.00, p b .001).
Follow-up subgroup GEEs with normal weight
individuals and underweight individuals indicated
FIGURE 2A Effect of text messages on precontemplation score (N = 12).
significant effects in the underweight group for
both precontemplation and action (precontempla-
tion score: Wald chi-square = 16.45, SE = 0.58,
p b .001; action score: Wald chi-square = 4.74,
SE = 4.07, p = .03). No significant effect was
found in the normal weight group on precontem-
plation scores (Wald chi-square = 0.25, SE = 1.83,
p = .62), but there was a significant effect of text
messages on action scores (Wald chi-square =
10.82, SE = 25.23, p = .001).
The interaction effect demonstrated that in
individuals who were underweight (BMI b 19.0)
there was a slight decrease in precontemplation
scores over time when receiving text messages. In
contrast, there was a sharper decrease in precon-
templation scores when not receiving text messages.
Additionally, the effect of text messages on reducing
precontemplation was greater at the beginning of
treatment, whereas the effect of not receiving text
messages on reducing precontemplation was greater
at the end of treatment (see Figure 2b). Individuals
who were normal weight (BMI N 19.0) did not
exhibit statistically significant differences in precon-
templation scores when receiving text messages
compared with not receiving text messages over
time (see Figure 2c).
With regard to the action scores, individuals who
were underweight reported overall higher action
scores when receiving text messages compared with
not receiving text messages (see Figure 3b). Individuals
who were normal weight reported increasing action
scores when receiving text messages and decreasing
action scores when not receiving text messages over
the course of the intervention. Additionally, not
receiving text messages had a greater effect on action
scores at the beginning of treatment and receiving text
 text message intervention for eating disorders 333

FIGURE 2B Effect of text messages on precontemplation scores in individuals who were underweight (n = 4).

messages had a greater effect on action scores at the
end of treatment (see Figure 3c).
Discussion
The primary aim of the current study was to pilot
a novel motivational text message intervention
for individuals with EDs. The intervention was
designed to be an adjunct to outpatient CBT and
focused on increasing kilocalorie intake, decreasing
dietary restraint, and increasing motivation to change
dietary restraint. The intervention was acceptable and
demonstrated potential feasibility. The effects of the
text messages on the primary outcomes, behavior
change, and motivation were mixed, and BMI status
moderated the effect of text messages on motivation.
feasibility and acceptability
The feasibility of the study was high, with approxi-
mately 90% compliance rate of data completion. This
is particularly encouraging because the majority of
the research to date in ED samples has collected EMA
data for up to 2 weeks (e.g., Lavender et al., 2013), or
in the case of EMIs, weekly for 16 weeks (Bauer et al.,
2012). Similar to the current study during which we
collected data daily for 8 weeks, only one other study
collected data daily for an extended time period
(12 weeks) and also reported high compliance
(Shapiro et al., 2010). These findings highlight the
potential feasibility of EMA methods that use longer
data collection periods in ED samples within the
context of monetary reimbursement.
This high compliance rate may have clinical
implications for monitoring homework in CBT.
Compliance with homework is associated with
positive treatment outcome (e.g., Kazantzis,
Whittington & Dattillio, 2010) and is a critical
component of CBT for EDs (Fairburn, 2008). The
smartphone provides a discreet method of completing

FIGURE 2C Effect of text messages on precontemplation scores in individuals who were normal weight (n = 8).
334 shingleton et al.

FIGURE 3A Effect of text messages on action score (N = 12).

monitoring on a device that participants likely carry
around throughout the day (Miller, 2012). Although
the current study did not use the smartphone for food
logs, multiple online programs have been developed
(e.g., Recovery Record, Rise Up) for ED food
monitoring. It is important to note that while
smartphones may be beneficial for treatment moni-
toring, the current participants were compensated for
high compliance, which may have motivated them to
be adherent to the nightly questionnaire. Future
research must investigate if monitoring without
monetary reward and/or while receiving pay-for-ser-
vice therapy results in equivalent compliance rates.
Nonetheless, the current data provide support for
using smartphones for monitoring, and future
research should investigate if homework that can be
collected via smartphone results in greater compli-
ance and ease of use for participants.
The participants reported liking the intervention
and, in general, they reported that the messages were
helpful reminders. The common positive themes that
emerged focused on the personalized nature of the
text messages, increased accountability when receiv-
ing the text messages and completing the monitoring,
and the helpful nature of the reminders to counter ED
thoughts and behaviors. Interestingly, two partici-
pants found the personalized nature of the text
messages detracted from the intervention, explaining
that the messages (a) seemed intrusive because they
referred to the MI session and (b) were reminders of
what the participant already knew. Multiple partic-
ipants wished they could have reached out in “real

FIGURE 3B Effect of text messages on action scores in individuals who were underweight (n = 4).
 text message intervention for eating disorders
FIGURE 3C Effect of text messages on action scores in individuals who were normal weight (n = 8).
time” for additional support and two participants also
did not like that the format of the actual message
began with “FRM:support@symtrend.com SUBJ:
Reminder from SymTrend” (a function of the
program that could not be altered) as opposed to
just the personalized text message content.
The participants’ feedback offers potential insight
for future research. First, given that some participants
did not like the personalized nature of the messages,
it may be worthwhile to tailor the messages to
individual preferences (e.g., if they prefer fact-based
messages as opposed to personalized messages).
Second, due to budget constraints and software
limitations, we were unable to allow for real-time
requests for support or reformat the messages. These
modifications could be beneficial for increasing
acceptability and efficacy in future research and
interventions.
Of note, a somewhat large proportion of individ-
uals were screened on the phone and were not eligible
(51/77) or were screened in person and were eligible
but did not enroll (7/20). All individuals calling for
treatment at the Eating Disorders Program were
asked if they were interested in the text message
study, and most of the people who were phone
screened but ineligible had diagnoses or symptoms
inconsistent with study criteria (e.g., binge eating
disorder, inadequate levels of restraint/restriction)
or were clearly unable to participate in the study
(e.g., were not able to attend regular sessions for
the required time period). Though our results are
generalizable only to the population that would be
eligible for participation, it appears that text message
studies are of interest to a wide range of individuals
with EDs and may bode well for future text message
studies recruiting individuals with many types of ED
symptoms. We hypothesize that the individuals who
335
were screened and deemed eligible but did not
participate or were lost to follow-up later found
themselves unable or unwilling to commit to the
study constraints (e.g., 8 weeks, weekly treatment
sessions) or were ambivalent about beginning
treatment for their ED. This highlights the difficulty
of recruiting ED samples in general.
text message effect: behavioral outcomes
Administration of the text messages did not show a
phase-specific significant effect on kilocalorie in-
take or dietary restraint across the group data. The
lack of behavioral change in response to the text
messages echoes past research failing to demonstrate
reduced ED behavior directly associated with MI-
based interventions (Knowles et al., 2013). While the
current research aimed to extend the motivational
intervention beyond a limited number of FTF sessions
by adding a novel factor of real-time reminders, our
results do not indicate behaviors changed in response
to the text messages for the whole sample.
Given that personalized motivational text mes-
sages did not trigger positive behavior change for
the majority of participants, it may be worthwhile
to investigate whether other types of messages
(e.g., supportive/encouraging messages such as
“You can do this!,” fact-based messages such as
“Low weight can lead to osteoporosis,” or pre-
scriptive messages such as “Eat three meals today”)
lead to behavior change. A recent study focused on
reducing smoking investigated the impact of web-
based prescriptive versus motivational messages
and found that participants viewed more of the web
content when receiving prescriptive messages
(McClure et al., 2013). A more directive approach
in this difficult-to-treat population may be more
effective.
336 shingleton et al.
It is also possible that the frequency of the text
messages may not have been high enough to motivate
behavior change. In the current study, three text
messages were sent per day during the text message
phases, and the messages were timed with the
participants’ typical mealtimes. Given that regular
eating involves two to three snacks in addition to the
three meals, it is possible that sending text messages at
snack times may have resulted in greater kilocalorie
intake. That being said, it is important that techno-
logy-based interventions are not intrusive; therefore,
future research should investigate the optimal number
and timing of motivational text messages to both
initiate change and avoid being burdensome.
Finally, our protocol involved treatment as usual
outpatient CBT for EDs. The treatment itself may
have been too potent for the adjunctive text messages
to add demonstrative value. Text messages may be
better suited to support lower intensity protocols such
as guided self-help or in a context where weekly
meetings are not feasible (e.g., rural settings).
text message effect: motivation to change
dietary restraint
The group effect of text messages on motivation was
more complicated than the effect on behavioral
outcomes. The text message effect on precontempla-
tion did not support our hypothesis that text messages
would increase motivation to change, whereas the
text message effect on action did support our
hypothesis. More specifically, precontemplation
decreased across all conditions but these scores
decreased less (i.e., individuals wanted to engage in
restriction more) when receiving text messages. At the
same time, when receiving text messages, they were
also actively working harder on not restricting (higher
action scores) when receiving text messages. These
findings are counterintuitive and highlight the com-
plex nature of motivation. The data may illustrate the
ambivalence ED patients feel when letting go of their
restrictive behavior, a behavior that aligns with their
shape and weight goals, but conflicts with broader life
goals. For example, it is possible that the text
messages increased the salience of their problematic
behavior, and in turn, increased their desire to engage
in restriction, resulting in higher precontemplation
scores. At the same time, the messages also included
why they did not want to restrict—which may have
led to increased action scores, motivating them to act
against their initial drive to engage in restriction.
The interaction effects of baseline BMI and text
messages on motivation outcomes are particularly
important given the range of BMIs included in the
current study. Individuals who were underweight
showed a negative impact of text messages on
precontemplation scores and a positive impact of
text messages on action scores. We hypothesize that
the text messages resulted in ambivalence in the
population where restriction was most effective at
achieving low weight—those with AN. However,
individuals who were normal weight demonstrated
no effect of text messages on precontemplation
scores, but demonstrated increasing action scores
when receiving text messages and decreasing action
scores when not receiving text messages. In addition,
action scores were highest at the end of treatment
when receiving text messages in the normal weight
group. It is possible that individuals with BN/
subclinical AN needed some time to “buy into”
treatment goals related to restraint more so than
individuals with AN because there were not as clear
physical signs of restraint (i.e., underweight status) in
the BN/subclinical AN sample. This may have
resulted in higher action scores in response to text
messages at the end of treatment when they had some
time to experience how dietary restraint negatively
impacted their ED symptoms as opposed to the
beginning of treatment when they were more naïve
about the impact of restraint on the ED cycle. Overall,
these results may also indicate that motivational
messages are more effective at increasing motivation
in normal weight individuals and may be more likely
to increase ambivalence in underweight individuals.
These statistical effects must be considered within
the context of clinical significance. We have data to
support that motivation to change predicts treatment
outcome in EDs, but it is unknown whether a 10%
decrease in precontemplation or a 20% increase in
action scores results in actual behavior change.
Research is needed to understand what magnitude
of change in motivation is needed to initiate ED-
related behavior change.
The current study has several limitations to note.
First, the limited diversity of the participants (majority
female and Caucasian) precludes the assumption of
broad generalizability of findings beyond individuals
with similar characteristics and clinical profiles.
Second, while we collected many observations, our
small n in the subgroup analyses may have limited our
power to detect important differences. Third, al-
though sequencing effects were controlled for in the
current study, there is a small possibility that some
carryover effects of the text messages may have
impacted outcomes. Future research using separate
control groups (e.g., RCT) would be beneficial to
further our understanding of the potential for text
messages to be used as an adjunctive intervention.
Fourth, no data were collected on intervention fidelity
for the MI session, text messages, or CBT delivered,
and not all of the therapists were fully blind to text
message condition, due to staffing constraints. Finally,
all the primary outcomes were self-report. Future
 text message intervention for eating disorders
EMA research may want to capitalize on new
technologies (e.g., Ginger.io, smartphone cameras)
that have the potential to collect real-time data beyond
self-report. Finally, motivation is a complex construct,
and our assessment of motivation, the RMQ, may
have impacted results.
Conclusion
The current research was the first study to use text
messages as a motivational adjunct to CBT for EDs.
We found evidence that the intervention was feasible
and acceptable in this sample, but while the text mes-
sages increased aspects of motivation, they had
minimal impact on changing behavior. Continued
empirical study is needed to uncover ways motiva-
tional interventions can lead to reduced ED symp-
toms, and replication studies are needed to understand
the conflicting effects text messages had on motivation
to change.
Conflict of Interest Statement
The authors declare that there are no conflicts of interest.
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