Table 1 Themes of the items of the ASTrA application and a description of the content

1

Do I have a weight problem, or more a fear of gaining weight?

Common thinking patterns: When I eat, I get anxious, panic and hate myself for letting myself go. I am very afraid of gaining weight

Feedback for reflection: Is it your weight that’s the source of your unhappiness? Or is it the constant fear of gaining weight?

Choice: Weight/Fear

Depending on the participant’s answer, more detailed reflective follow-up questions appear on the screen about the possible cause of distress (weight vs. fear of gaining weight). The idea of EDs as a weight gain phobia is explained and how by gradually letting go of restricting, a person can discover that there is no need to restrict to control weight

2

Does losing weight solve my problem?

Common thinking patterns: If only I can get my weight down a bit more, I’ll feel better. More confident. More attractive. More in control

Feedback for reflection: Does losing weight really help you feel better?

Choice: Yes/No

Depending on the participant’s answer, reflective follow-up questions appear on the screen about whether losing weight causes temporary positive feelings such as more self-confidence vs. whether losing weight did not make fears of gaining weight or body-image concerns go away in the long term

3

Set point is nature’s parachute

Common thinking patterns: I feel that I must be very careful about how much I eat. When I eat even a little more, my weight goes up. I see it on the scale right away. It’s like I gain weight very easily. Is it really supposed to take so much work to avoid weight gain?

Feedback for reflection: Are you trying to maintain your weight below the one that is natural for you?

Choice: Yes/No, followed by psychoeducational information about set-point. Specific content depends on the answer of the participant

4

You cannot maintain your weight (unless at your set point)

Common thinking patterns: My weight is pretty good now…and it’s as high as I want it to go…any higher and I’ll want to restrict some more. After all, I’m not physically ill anymore, I’m not in any danger. I’ll just watch what I eat and keep the weight I have now

Feedback for reflection: Do you think it is possible to maintain your weight below your Set Point?

Choice: I can try/Don’t even try

Depending on the participant’s answer, reflective questions appear on the screen around the feasibility to maintain a weight below set point vs. how a weight below set point could re-trigger a cycle of being over-cautious and undereating

5

No weight is good enough

Common thinking patterns: If only I was able to get down to “xx” kilograms, I would feel better, more confident and I could stop worrying about my weight all the time. Just a little more ought to do it

Feedback for reflection: Really? Have you ever achieved a weight at which discomfort and worry about your weight and body image really went away, and no longer left you distressed?

Choice: Yes/No

Depending on the participant’s answer, reflective questions appear on the screen around whether weight loss leads to positive feelings that are temporary vs. whether weight loss made body preoccupations and worries about the risk of regaining weight not go away

6

Paradoxically, you reduce binge-eating by eating more

Common thinking patterns: I have to be careful not to eat past a certain point, because if I do it will trigger a binge. I don’t know what’s with me. I just can’t control myself. I’m some kind of food junkie

Feedback for reflection: Are you someone who can’t say “No” to food? Or is it more likely that you are chronically under-fed, or very often thinking about how you need to eat less? For example, when was the last time you regularly ate 3 meals a day?

Choice: It’s been a long time/ I always eat 3 balanced meals/day

Depending on the participant’s answer, reflective questions appear on the screen around whether restriction or thinking about dieting/restricting could increase risk for bingeing vs. how regular eating helps to control appetite

7

Full is not fat

Common thinking patterns: I hate feeling full. I can see my stomach bloat and I feel fat

Feedback for reflection: People with eating disorders often complain that they are prone to uncomfortable feelings of fullness or bloating, or uncomfortable stomach acidity, burning, reflux, or cramps. They even say that their stomachs bloat out after eating relatively small amounts of food. Do you have that? Do you stop eating before you feel full in order to avoid the uncomfortable feeling of fullness?

The preceding reflective questions are followed by presenting information about how regular eating reduces bloating or other digestive issues

8

Rapid weight gain (or loss) is not real

Common thinking patterns: I am someone who gains weight very easily, so I have to be very cautious about what or how much I eat

Feedback for reflection: Human bodies don’t gain or lose body mass very rapidly. Body mass change is a very slow process that takes weeks, or even months. Rapid weight changes are due to changes in hydration (water). You lose water (by sweating, urinating, restricting, or purging). Your body can gain (or lose) several kilos of water weight very quickly (within a day). Many people get fooled into reacting to (or compensating for) meaningless, rapid changes in weight that are due only to water retention and water loss

The rule is: If the change happened quickly, it is NOT REAL

9

Are you the person you want to be?

Point for reflection: When acting on your eating disorder (dieting, restricting, controlling weight, being body preoccupied, etc.) are you really being true to your own values? I mean are you giving priority to the things that really matter to you? To help you consider this question, please click the values that you consider to be the most important for you. [table with 62 values, values light up as they are clicked]

Are you giving more space to the values that are important to your eating disorder or to those that are important to you? Can you make more space for your own values? YOUR priorities? Taking time to identify your values helps to give meaning to your life, especially if you behave in a way that is aligned with your values. Can you think of specific actions you could do this week that would bring you closer to your values?

10

There are other ways to manage emotions besides relying on eating-disorder behaviours

Common thinking patterns: When my emotions get really strong, I can’t handle them. They overwhelm me. My eating disorder helps me escape from strong emotions, or at least to keep them in check.

Feedback for reflection: When you try to avoid, push away, or escape from emotions, it may work in the short-term. But, have you noticed that the emotions tend to come back, sometimes even stronger?

Eating disorder symptoms can be a coping mechanism people develop to push away their emotions. This can “work” in the short-term but tends to bring about various negative consequences. Using the eating disorder to deal with emotions can block you from developing more-effective ways of coping with emotions and comes at a high price. Which of the following are part of the price you pay for your eating disorder symptoms?

[14 problem behaviours appear]

One of the things we work on in eating-disorder treatment is developing effective ways of soothing emotions

11

Being thinner is the key to happiness

Common thinking patterns: People tell me to stop dieting and to stop watching my weight. They say that I don’t eat enough. But I like what I see in the mirror right now. Why should I change that? I don’t tell them what to do

Point for reflection: Even though weighing less has some positive aspects for you, are you sure it’s worth it?

Choice: Yes/No

Depending on the participant’s answer, reflective questions on whether or not weighing less is worth it in the long run. The participant is then asked to indicate what percentage of mental energy goes into thinking about weight, body image and eating (< 30%, 30–50%, 50–75%, 75–100%), and asked to reflect on whether or not that percentage is too much (choice: yes/no). If answer is no, a checklist of six possible psychological costs of eating, weight and body-image concerns appears, and the participant is asked to reflect and tick all that apply

12

I need to “make room” to let myself eat

Common thinking patterns: In order to allow myself to eat, I must first burn the calories either by exercising, purging or by restricting my intake. The higher the energy expenditure, the more I am allowed to eat

Feedback for reflection: Did you know that your body needs energy even when you are at rest? The body needs fuel (and therefore food) to function properly, even if you haven’t exercised. It isn’t necessary to use compensating behaviors to give yourself permission to eat. Your body actually requires energy to function!

Psychoeducation is given around the body’s energy needs