“There’s an app for that.” 21st Century Tools for Behavior Change

Have you ever set out to wake up earlier and found that by week two, you are back to repeatedly hitting the ‘snooze’ button? Have you promised yourself that you will start eating breakfast every day, but struggled to make the change stick? If you’ve ever tried to alter any behavior (and if you are human, then the likely answer is “yes!”), then you know how incredibly hard it can be.

Self-monitoring, the systematic, in-the-moment recording of actions is one of the best tools to make behavioral change.  The logic is straightforward: observe and record your behavior to make and measure change.   Self-monitoring is a cornerstone of successful weight loss programs. It is a critical component of interventions aimed to restore a normal pattern of eating in bulimia nervosa and binge eating disorder and to gain and maintain weight (e.g., increase portions and varieties of foods) in anorexia nervosa.


Paper and pencil monitoring may soon be eclipsed by electronic methods, as smartphone and tablet technology gain popularity. Two main categories of food and exercise monitoring methods have emerged: 1) applications that can be downloaded, often free of cost, to smartphones or tablets devices and 2) “wearables” including fashionable wrist watches, bracelets or other accessories that can be clipped discretely to clothing. There are apps that focus primarily on calorie counting and other apps, intended more specifically for individuals with eating disorders, which emphasize meal patterns and emotional wellbeing as related to the experience of eating.

Unlike the paper and pencil records that are cumbersome to carry or awkward to access in public, these electronic counterparts are readily accessible on devices that already go everywhere with us, may allow for real time recording with greater accuracy, and might be more agreeable to those doing the hard work of monitoring behavior. Technology may also allow those who are unable to receive in-person treatment to benefit from a tried-and-true behavior change tool.

Does this technology work?  It’s too soon to tell for certain because the scientific research has been outpaced by the speed of technological innovations. Initial results do suggest that electronic dietary records produce more accurate recordings, though it is uncertain if enhanced accuracy persists over time. Even when records indicate behavioral dietary change, this has not been clearly linked with an effect on overall outcome. The accuracy of wearables for some kinds of activities is also in question. And studies in those with eating disorders are quite sparse.

As we wait for more definitive data, proceeding thoughtfully with electronic self-monitoring tools is important and might involve consideration of an individual’s specific goals and diagnosis.

Individuals who are overweight and obese are encouraged to be mindful of calories and increase physical activity, to make healthy life style choices to lose weight. The breadth of available tracking devices, from apps to wearables, could arguably be appropriate for this pursuit. A few notes of caution: calorie counters are not nutritionists and may unduly make the focus on a goal calorie number, rather than healthy meal choices that acknowledge nutritional needs and cardiovascular and diabetic risks. Likewise, wearables are not personal trainers, and do not provide guidance about how to combine strength training and cardiovascular activity to decrease body fat while maintaining healthy muscle mass.

For individuals working to overcome the cycle of restriction, binge eating and purging characteristic of bulimia nervosa or the frequent episodes of binge eating typical in binge eating disorder, treatment focuses on establishing a regular routine of meals and snacks with balanced food choices. The purpose of self-monitoring is to implement structure. In anorexia nervosa, meal planning is crucially important for weight restoration and maintenance.  Treatment teams often establish calorie prescriptions to meet therapeutic goals while simultaneously working to help the individual decrease preoccupation with calories and restriction.

Across the spectrum of eating disorder diagnoses, apps that count calories may interfere with wellness goals, possibly unnecessarily increasing an individual’s focus on the numerical aspects of diet that can be closely tied with negative evaluations of self, body shape, and weight in those with these disorders. A similar argument can be made against use of wearables in this population.  These devices might enhance the focus on numbers (for example, number of steps taken per day), rather than the broadly defined physical and psychological benefits of exercise. Apps geared specifically to individuals with eating disorders are likely the best to try first. There are also more general apps that help people to tally the occurrence of any behavior of interest; this could be useful for more varied goals in eating disorder treatment, such as limiting body-checking.

At their best, apps and wearables may help patients to integrate self-monitoring into their daily routine to meet their specific goals.  At their worst, this self-monitoring technology might foster an unhealthy obsessionality with numbers. As we move beyond simply saying, “there’s an app for that,” it is the shared responsibility of patients, providers, and the public to ensure that the use of these novel tools is for the greater good, to promote health and wellbeing without simply reducing the conversation to numbers.

Photo credit (front page): Creative Commons by Sean MacEntee

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