Thesis

Virtual Coaching for Emotional Eaters FOOD FOR THOUGHT Aranka Dol

Virtual Coaching for Emotional Eaters FOOD FOR THOUGHT Aranka Dol

Colofon Virtual Coaching for Emotional Eaters Food for thought Design/Lay-out Proefschriftenbalie, Nijmegen Images cover and titlepages Groep Marionne Bos (CMD, 2020) Print Ipskamp Printing, Enschede ISBN (print): 978-90-365-5763-4 ISBN (digitaal): 978-90-365-5764-1 URL: https://doi.org/10.3990/1.9789036557641 © 2023 Aranka Dol, The Netherlands. All rights reserved. No parts of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the author. Alle rechten voorbehouden. Niets uit deze uitgave mag worden vermenigvuldigd, in enige vorm of op enige wijze, zonder voorafgaande schriftelijke toestemming van de auteur.

Virtual Coaching for Emotional Eaters FOOD FOR THOUGHT Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Twente, op gezag van de rector magnificus, prof. dr. ir. A. Veldkamp, volgens besluit van het College voor Promoties in het openbaar te verdedigen op maandag 13 november 2023 om 14.45 uur door Aranka Dol geboren op 19 mei 1962 in Zaandam, Nederland

Dit proefschrift is goedgekeurd door: Promotoren Prof. dr. ir. J.E.W.C. van Gemert-Pijnen Dr. C. Bode (ius) Copromotor Dr. H. Velthuijsen

Promotiecommissie Voorzitter / secretaris: Prof. dr. T. Bondarouk Promotoren: Prof. dr. J.E.W.C. van Gemert-Pijnen Universiteit Twente Dr. C. Bode (ius) Universiteit Twente Co-promotor: Dr. H. Velthuijsen Hanze University of Applied Sciences Leden: Prof. dr. C.J.M. Doggen Universiteit Twente Prof. dr. M.L. Noordzij Universiteit Twente Prof. dr. E.W.M.L. De Vet Wageningen University Prof. dr. L. Goossens Universiteit Gent Prof. dr. R. Sanderman Rijksuniversiteit Groningen

Contents Chapter 1 General Introduction & Outline 9 Chapter 2 Developing a Personalised Virtual Coach ‘Denk je zèlf!’ for Emotional Eaters Through the Design of Emotion-Enriched Personas 29 Chapter 3 The Application of Validating and Dialectical Coaching Strategies in a Personalised Virtual Coach for Obese Emotional Eaters – Rationale for a Personalised Coaching System 55 Chapter 4 Application of three different coaching strategies through a virtual coach for people with emotional eating: a vignette study 75 Chapter 5 Preferences for coaching strategies in a personalized virtual coach for emotional eaters: an explorative study 107 Chapter 6 Exploring Tailored Virtual Emotion Regulation Approaches for Individuals with Emotional Eating 147 Chapter 7 G eneral Discussion 195 Appendices Summary in Dutch 223 Acknowledgement 236 Publications 239 About the author 243

CHAPTER 1 General Introduction & Outline

General Introduction & Outline 11 1 Emotional eating: food for thought Persona Lisanne “I wish that I was more confident about myself …” Source: Shutterstock.com Figure 1 | Persona Lysanne This is Lisanne. She is one of the personas1 that was developed during this study. Lisanne is an emotional eater. According to van Strien emotional eating is the “tendency to overeat in response to negative emotions such as anxiety or irritability” [1]. For emotional eaters, eating and giving in to binge eating and or overeating, is a natural coping mechanism to deal with negative emotions [2-4]. If this behaviour is often repeated, it can lead to (severe) weight gain and even obesity [5-9]. According to the World Health Organization the obesity epidemic [10] has long been at the top of the charts as being a major societal problem in Europe. A population that is increasingly overweight and obese is causing a significant increase in chronic patients with an arsenal of co-morbidities, such as metabolic syndrome (diabetes II), cardiovascular disease, joint problems, and cancer [11-13], and consequently rising healthcare costs and overburdening the healthcare system [14-15]. Demographics Single; Lives alone. High school graduate. Suffers from obesity. Co-morbidities unknown. Length 1.62 mtr.; weight 91 kgs. Attributes Feels insecure about her body. Is not able to sense the difference between hunger, appetite, or emotions. Fears experiencing what she really feels. User needs Education on eating behaviour. Self-confidence. Help to set realistic goals. Support from peers. 1 A persona is a fictional representative of a target group

Chapter 1 12 Common ways to control lifestyle-related obesity -eat less, exercise more- only help in the short term [16-18]. In fact, after every dieting attempt, the weight comes right back on. Science has shown that dieting is not the answer [19-21]. In fact, dieting does nothing to address why emotional eaters became overweight in the first place, namely emotional eating. Plusminus 40-60% of overweight or obese people are emotional eaters [22-23]. Emotional eaters are more likely to be overweight or obese, than individuals without emotional eating behaviour [24-25]. Emotional eating behaviour is possibly caused by, among other things, genetic vulnerability [25-26] a “biologically based sensitivity that interacted with the environment in which one was raised and specific life events one faced – the ‘social’ part of biosocial” [27, p. 28]. An invalidating environment can have caused chronic stress during childhood, such as neglect, being abandoned by parents, patronizing, and abuse [28]. Beijers and Van Strien postulate that the quality of the parent-child relationship in early childhood, in the capacity of care and attachment, may be a predictor for the development of emotional eating behaviours in the adolescent years [29]. Emotional eaters suffer from reduced interoceptive awareness, a poor vision of what is happening in one's own body [30], and a high degree of alexithymia (the inability to identify and describe emotions experienced by oneself [31-32]. Emotional eaters eat more when experiencing negative emotions, such as stress or anxiety, in a quest for well-being. This is atypical behaviour, because normally when people have stress or anxiety, they have no desire to eat at all [2, 33]. Most people go straight into the so called fight-or-flight mode [34]. In threatening situations that cause a lot of stress, the human body's natural survival mechanism is triggered by a chain reaction of hormonal processes [2]. These processes cause the stomach contractions to stop, and to suppress feelings of hunger. Blood is sent to the muscles so the body can prepare for action [6, 35-36]. Treating emotional eating behaviour Successful ways to treat emotional eating behaviour include mindfulness, Cognitive Behaviour Therapy [5, 37], and Dialectical Behaviour Therapy [27-28, 38]. Mindfulness can be effective in treating emotional eating behaviour. Studies reported decrease of emotional eating, due to decrease in perceiving stress [39-42]. Cognitive Behaviour Therapy seems effective in terms of weight loss and reducing emotional eating [5, 37], but high scores on emotional eating were predictors of treatment resistance [43]. A combination of CBT with mindfulness resulted in greater reductions perceived stress and stress-eating [44].

General Introduction & Outline 13 1 Dialectical Behaviour Therapy (DBT) was originally developed for people with severe borderline problems [45]. DBT is an elaboration of Cognitive behaviour Therapy where the emphasis is on learning and applying new skills to deal more effectively with emotions and life problems. DBT has a number of (coaching) strategies (including cognitive behavioural therapy, validation, and dialectics) that are specific to this therapy and have been studied for their effectiveness in group therapies in the clinical setting [27-28, 38, 46-47]. Emotional eaters can seek help from the specialized dietician, who has knowledge of emotional eating [48-49], and from the mental health care worker in the General Practice. This employee, usually trained as a social psychiatric nurse, social worker or (basic) psychologist, supports the General Practitioner in the supervision and treatment of patients with (mild) psychological, psychosocial or psychosomatic complaints [50-51]. Obese emotional eaters can also be treated in combined lifestyle interventions with a multidiciplinary approach [52]. Psychologists in primary mental health care provide short-term training in emotion regulation, mindfulness, intuitive eating [53-54]. Psychologists and psychiatrists in the secondary mental health care provide long-term clinical programs in Dialectical Behaviour Therapy and Cognitive Behavioural Therapy [55]. What holds back treatment? Unfortunately, the current provision of care does not fully meet the needs of the emotional eater. Firstly, there is a perceived distance to health care among emotional eaters. They are ashamed of their eating problem [56] and will not readily seek care [56-59]. Emotional eaters do not tend to share their problems with friends or family, nor will they discuss with their GP (General Practitioner) that they have a problem with eating behaviour [56], thus, a significant proportion of emotional eaters remain invisible to the outside world [60-62]. If they come to the GP for help at all, it is not the eating problem itself that is discussed, but problems arising from obesity, such as diabetes or knee problems [16]. There is little chance that the eating problems will be recognized or even diagnosed [60, 63]. Secondly, only limited care is available. Emotional eaters in the Netherlands have difficulty accessing existing health care services. Only a restricted group of dieticians has (nutritional) knowledge of emotional eating behaviour [48-49]. Dieticians often lack specialist skills to provide best practice care for people with eating disorders [64].

Chapter 1 14 Health care is overburdened and not readily available. The mental health care worker (affiliated to a general practise) usually has 5-7 sessions available [50]. There are long waiting lists for inpatient care, and for mental health care [65-66]. The healthcare sector is experiencing major problems, both financial and organizational [51, 67-68]. There is a large staff shortage so health care workers are no longer able to provide the care according to the standards they are used to. Lastly, health care is to date not able to provide support at the time emotional eaters need it most, i.e. at the time of experiencing cravings. They usually do not experience cravings or binge eating during sessions with a therapist, but may do so late at night when nobody is available to provide counseling. Towards another approach? The summation of coping with a complex problem, in which help must be provided to people who are distant from care, and for whom it is almost impossible to deliver health care in the right time, calls for different and creative solutions. In a world where the accessibility of timely care is no longer feasible, it becomes essential to explore online self-help approaches. Such a facility provides remote support and can assist target groups such as emotional eaters with appropriate feedback at the moment they need it most. The target group should be enticed to deal with their problem independently, without the intervention of care services. After all, if a problem situation typical of emotional eaters arises, they will still have to face it independently. Self-management could be an important component in the treatment of emotional eating behaviour. A promising approach to support emotional eters could be virtual coaching. We suspect that this group may benefit from this type of online remote support [69], because they can independently, and on their own initiative, use personalized support, at a time of their choosing, without the need for physical intervention by a caregiver. Within the privacy of their own home, clients can engage in learning about and becoming more knowledgeable about their condition. To clarify, when we refer to virtual coaching, we are specifically referring to coaching conducted digitally through the use of a virtual assistant (such as a chatbot) in any capacity and at any given time. This can encompass both an online format and a hybrid form. For the purposes of this study, we will focus on the online aspect.

General Introduction & Outline 15 1 In the last two decades, the development of virtual coaching has made considerable progress. It is not yet easy to give an unambiguous definition of what a virtual coach is. It is more important to look at the functional characteristics that make a virtual coach an effective coach and add value for the specific target group. A virtual coach can play a role in lifestyle and/or behaviour change [69-71]. Application areas of virtual coaching include supporting healthy lifestyle dealing with chronically illness, [72], coping with cardiovascular disease [73], handling andmonitoringDiabetes II [74-76], promoting adherence to self-isolation during the Covid pandemic [77], and coaching intended for specific groups such as people with low socioeconomic status [78], and indigenous people [79]. Virtual coaching is also applied in mental health and offers support and help with eating disorders, depression, and anxiety. Approaches used include ACT [80], Cognitive Behavioural Therapy [81-82], and Dialectical Behavioural Therapy [83-85]. From the reviews by Wilks et al, and Xie et al, as cited above, it appears that Dialectical Behaviour Therapy in virtual coaching is primarily used for Borderline Personality Disorder. The desire to use DBT in the capacity of virtual coaching is motivated by the same as with emotional eaters, according to Xie et al. “...access to traditional therapistdelivered psychotherapies such as DBT may be limited for many people due to costs, mental health stigma, and logistical barriers such as travel required to attend therapy appointments. For many, therapists trained in DBT are simply not accessible.” [85]. Literature also suggests that virtual coaching applications for DBT do not appear to be just online replicas of the face-to-face therapy. The application of DBT consists of “using DBT techniques”, “based on DBT”, “including DBT elements”, “inspired by DBT”, “DBT informed”, “internet based DBT (i-DBT)”, and “internet delivered DBT” [83, 85-86]. It is apparently feasible to help patients online with parts of the DBT therapy. Spurred by the recent Covid pandemic, there is a desire among DBT therapists ‘to move forward on telepsychology applications’ but there is an urgent need to compare standard DBT to online or blended DBT [87-88]. Although the internet has a great potential to deliver psychological interventions, smartphone-based interventions in the capacity of virtual coaching for emotional eaters remain scarce. Emotional eaters are a group of people who, for reasons mentioned above, keep their distance from care. Because emotional eating can be associated with obesity, it is even more important that this group also get the help and support it needs. Currently, the availability of suitable treatment or support is poor. DBT seems to be a promising way, but it is not yet available on a larger scale.

Chapter 1 16 It is our aim, by conducting exploratory research, to gather knowledge and insight about the target group, with the goal of learning more about the characteristics of the virtual coach to be developed, that makes it effective for the target group of emotional eaters, using elements from the DBT. This thesis This paragraph entails the Aims and research question we want to answer followed by this thesis. The booklet consists of five publications, being the five chapters that together present a narrative about the realization of this research. This thesis consists of seven chapters. Chapter 2 and 3 focus on conducting a design case study, followed by a rationale for designing a Personalized Virtual Coach. Chapter 4, 5 and 6 focus respectively on the application of coaching and emotion regulation approaches, testing them in real-life settings with participants, originating from the target groups. Chapter 7 encompasses the overall discussion. Our study does not involve the development of a functional prototype; instead, it concentrates on examining the prerequisites and designing aspects of the application. Aim and research question The aim of this thesis is to gain knowledge to support emotional eaters to cope with emotional eating behaviour in a self-help setting, a setting that matches the right moment, and is in line with the context. To accomplish this, we must gain knowledge about the needs of emotional eaters in terms of virtual coaching and self-management. This results in the following research question: “How can virtual coaching facilitate emotional eaters to cope with self management of their emotional eating behaviour?” Chapter 2 “Developing a Personalised Virtual Coach ‘Denk je zèlf!’ for Emotional Eaters through the Design of Emotion-Enriched Personas” focuses on conducting a design case study aimed at identifying the needs of the target population. A contextual inquiry will be performed by collecting data via questionnaires and interviews, with emotional eaters and healthcare practitioners (dieticians, physical therapists and psychologists), to develop personas2 according to the classification model of LeRouge, and van Velzen [89-90], as a starting point to derive a conceptual user model on technical, demographic and care-specific characteristics. The aim of this design case study is to develop a protoype of a virtual coach. 2 A persona is a virtual representative of a target group (bron)

General Introduction & Outline 17 1 Chapter 3 “The Application of Validating and Dialectical Coaching Strategies in a Personalised Virtual Coach for Obese Emotional Eaters. Rationale for a Personalised Coaching System” describes a design rationale for a virtual coach presenting the components and functionalities that provide a system for self management for emotional eaters, using the results of the design case study in Chapter 2, and the personas developed from there. In this chapter, we introduce a research protocol that focuses on the implementation of coaching strategies and skill exercises derived from Dialectical Behavior Therapy for participants. The coaching strategies are presented through the personas, which were developed and discussed in the preceding chapter. In the Chapters 4 and 5, the vignettes methodology is employed (using two different study populations), wherein the personas created in Chapters 2 and 3 are utilized to represent the two significant scenarios commonly encountered by individuals with emotional eating: 1. experiencing cravings, and 2. after giving into cravings. These personas are presented to participants online, followed by the provision of potentially suitable coaching strategies. Chapter 4 “Application of three different coaching strategies through a virtual coach for people with emotional eating: a vignette study” describes the conduct of the qualitative study. In this chapter we will attempt to answer the question of whether adult participants with emotional eating behaviour identify themselves with the situations as presented using personas, and which coaching strategy matches the needs of adults with emotional eating. Chapter 5 “Preferences for coaching strategies in a personalized virtual coach for emotional eaters: an explorative study” reports about the conduct of the quantitative study. In this chapter we will attempt to explore if there are predictors for identification with the typical problem situations for emotional eaters ‘experiencing cravings’ and ‘after giving in to cravings’ and what are the preferences for a specific coaching strategy with regards to the two typical problem situations for emotional eating. Questionnaires on emotional eating (DEBQ), personality traits (Big-5), well-being (PANAS), and BMI will be administrated to gain further insights into the potential of tailored coaching. Chapter 6 (“Exploring Tailored Virtual Emotion Regulation Approaches for Individuals with Emotional Eating”) covers an embedded mixed-method design study on exploring a tailored online approachwith the aim to positively influence affect (positive and negative) and emotion regulation by studying three exercises based on dialectical behavioural therapy. We will explore effects and perceived usefulness of tailored exercises in emotion regulation.

Chapter 1 18 In Chapter 7 the outcomes of the general research question will be discussed: “How can virtual coaching facilitate emotional eaters to cope with self management of their emotional eating behaviour?”

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General Introduction & Outline 23 1 [53] Rijksoverheid.nl. https://www.rijksoverheid.nl/onderwerpen/geestelijkegezondheidszorg/ basis-ggz-en-gespecialiseerde-ggz Retrieved 06-12-2022 retrieved 06-12-2022 [54] Basis GGZ en gespecialiseerde GGZ, retrieved 06-02-2023); https://www.rijksoverheid.nl/onderwerpen/geestelijke-gezondheidszorg/basisggz-en-gespecialiseerde-ggz [55] GGZ Standaarden. Zorgstandaard Eetstoornissen. Behandeling en Begeleiding. Deze pdf is gepubliceerd op 21-03-2023 om 11:59. https://www.ggzstandaarden.nl/zorgstandaarden/eetstoornissen/behandeling-enbegeleiding. retrieved 31-03-2023. [56] Wong, M., & Qian, M. (2016). The role of shame in emotional eating. Eating Behaviors, 23, 41–47. https://doi.org/10.1016/j.eatbeh.2016.07.004 [57] Ferreira C, Pinto-Gouveia J, Duarte C. Self-compassion in the face of shame and body image dissatisfaction: implications for eating disorders. Eat Behav. 2013;14:207–10. [58] Rørtveit K., Åström S., and Severinsson E. The meaning of guilt and shame: A qualitative study of mothers who suffer from eating difficulties. Int J Ment Health Nurs. 2010;19:231–9. [59] Goss, K., & Allan, S. (2009). Shame, pride and eating disorders. Clinical Psychology & Psychotherapy, 16(4), 303–316. https://doi.org/10.1002/cpp.627 [60] Heins et al, 2021. Zorg door de huisarts. Nivel Zorgregistraties Eerste Lijn: jaarcijfers 2021 en trendcijfers 2017-2021. Marianne Heins, Julia Bes, Yvette Weesie, Rodrigo Davids, Marcus Winckers, Leontien Korteweg, Elsbeth de Leeuw, Tom Urbanus, Liset van Dijk, Joke Korevaar, Jeroen Hasselaar, Karin Hek. Aug 2022. ISBN 978-946122-756-0. Retrieved from: https://www.nivel.nl/nl/nivel-zorgregistraties-eerste-lijn/cijfers-zorg-huisartshuisartsenpost-paramedici/cijfers-zorg-huisartsen [61] Seah, X. Y., Tham, X. C., Kamaruzaman, N. R., & Yobas, P. K. (2017). Knowledge, attitudes and challenges of healthcare professionals managing people with eating disorders: a literature review. Archives of Psychiatric Nursing, 31(1), 125–136. https://doi.org/10.1016/j.apnu.2016.09.002 [62] GGZ Standaarden. Richtlijn eetstoornissen 2008.PDF Hoofdstuk 5 Diagnostiek. https://www.ggzstandaarden.nl/richtlijnen/eetstoornissen-richtlijn-2008/ introductie. [63] Hek, K., Dijk, L. van. Zorg bij de huisarts - Aard, omvang en kwaliteit. Uit: www.nivel.nl [Laatst gewijzigd op 12-02-2023; geraadpleegd op 04-03-2023]. https://www.nivel.nl/nl/nivel-zorgregistraties-eerste-lijn/cijfers-zorg-huisartshuisartsenpost-paramedici/cijfers-zorg-huisartsen

Chapter 1 24 [64] Davis, A., Meloncelli, N., Hannigan, A., & Ward, W. (2022). Evaluation of a model of online, facilitated, peer group supervision for dietitians working in eating disorders. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00617-7 [65] Vektis. https://www.vektis.nl/intelligence/publicaties/factsheetwachttijdinformatie-ggz. Retrieved 06-12-2022. [66] Patientenfederatie. https://kennisbank.patientenfederatie.nl/app/answers/ detail/a_id/419/~/wachtlijsten-in-de-ggz. Retrieved 06-12-2022. [67] Nationale Onderwijsgids. https://www.nationaleonderwijsgids.nl/voortgezetonderwijs/nieuws/ 57433-ggz-totaal-overbelast-door-toename-psychischeproblemen-onder-jongeren.html; Retrieved 06-12-2022. [68] Zorginstituut. https://www.zorginstituutnederland.nl/publicaties/ rapport/2019/02/12/onderzoek-op-zoek-naar-passende-zorg-problemen-dieggz-patienten-ervaren#:~:text=De%20problemen%20die%20ervaren%20 worden,komen%20bij%20veel%20cli%C3%ABnten%20voor. [69] Chatterjee, A., Gerdes, M., Prinz, A., & Martinez, S. (2021). Human coaching methodologies for automatic electronic coaching (ecoaching) as behavioral interventions with information and communication technology: systematic review. Journal of Medical Internet Research, 23(3), 23533. https://doi.org/10.2196/23533 [70] Granja, C., Janssen, W., & Johansen, M. A. (2018). Factors determining the success and failure of ehealth interventions: systematic review of the literature. Journal of Medical Internet Research, 20(5), 10235. https://doi.org/10.2196/10235 [71] Beun, R. J., Anderson, J., Ham, J., Klein, M., Roefs, A., & Westerink, J. (2017). Special issue on supporting a healthier lifestyle with ecoaching systems. Personal and Ubiquitous Computing, 1-3, 1–3. https://doi.org/10.1007/s00779-017-1029-x [72] Tornivuori, A., Tuominen, O., Salanterä, S., & Kosola, S. (2020). A systematic review on randomized controlled trials: coaching elements of digital services to support chronically ill adolescents during transition of care. Journal of Advanced Nursing, 76(6), 1293–1306. https://doi.org/10.1111/jan.14323 [73] Yousuf, H., Reintjens, R., Slipszenko, E., Blok, S., Somsen, G. A., Tulevski, I. I., & Hofstra, L. (2019). Effectiveness of web-based personalised ecoaching lifestyle interventions. Netherlands Heart Journal, 27(1), 24–29. https://doi.org/10.1007/ s12471-018-1200-7 [74] Castro Sweet CM, Chiguluri V, Gumpina R, Abbott P, Madero EN, Payne M, et al. Outcomes of a Digital Health ProgramWith Human Coaching for Diabetes Risk Reduction in a Medicare Population. J Aging Health 2018 Jun 01;30(5):692-710. [doi: 10.1177/0898264316688791] [75] den Braber N, Vollenbroek-Hutten MMR, Oosterwijk MM, Gant CM, Hagedoorn IJM, van Beijnum BF, et al. Requirements of an Application to Monitor Diet, Physical Activity and Glucose Values in Patients with Type 2 Diabetes: The Diameter. Nutrients 2019 Feb 15;11(2):409 [FREE Full text] [doi: 10.3390/nu11020409]

General Introduction & Outline 25 1 [76] Stevens, S., Gallagher, S., Andrews, T., Ashall-Payne, L., Humphreys, L., and Leigh, S. (2022). The effectiveness of digital health technologies for patients with diabetes mellitus: a systematic review, 3. https://doi.org/10.3389/fcdhc.2022.936752. [77] van ’t Klooster, J.W.J.R., van Gend, J.E., Schreijer, M.A., de Witte, E.R., van GemertPijnen, L. (2022). The Value of eCoaching in the COVID-19 Pandemic to Promote Adherence to Self-isolation and Quarantine. In: Kim, JH., Singh, M., Khan, J., Tiwary, U.S., Sur, M., Singh, D. (eds) Intelligent Human Computer Interaction. IHCI 2021. Lecture Notes in Computer Science, vol 13184. Springer, Cham. https://doi. org/10.1007/978-3-030-98404-5_39; [78] Spelt, H., Westerink, J., Tsiampalis, T., Karnaki, P., Kouvari, M., Zota, D., & Linos, A. (2019). Lifestyle ecoaching for physical activity level improvement: short-term and long-term effectivity in low socioeconomic status groups. International Journal of Environmental Research and Public Health, 16(22). https://doi.org/10.3390/ ijerph16224427 [79] Li, J., & Brar, A. (2022). The use and impact of digital technologies for and on the mental health and wellbeing of indigenous people: a systematic review of empirical studies. Computers in Human Behavior, 126. https://doi.org/10.1016/j. chb.2021.106988 [80] Herbert, M. S., Dochat, C., Wooldridge, J. S., Materna, K., Blanco, B. H., Tynan, M., Lee, M. W., Gasperi, M., Camodeca, A., Harris, D., & Afari, N. (2022). Technologysupported acceptance and commitment therapy for chronic health conditions: a systematic review and meta-analysis. Behaviour Research and Therapy, 148. https:// doi.org/10.1016/j.brat.2021.103995 [81] Fitzpatrick, K. K., Darcy, A., & Vierhile, M. (2017). Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (woebot): a randomized controlled trial. Jmir Mental Health, 4(2), 19. https://doi.org/10.2196/mental.7785 [82] Kerstin Denecke, Nicole Schmid, Stephan Nüssli, Implementation of Cognitive Behavioral Therapy in e–Mental Health Apps: Literature Review. J Med Internet Res 2022. vol. 24, iss. 3 https://www.jmir.org/2022/3/e27791 [83] Wilks CR, Lungu A, Ang SY, Matsumiya B, Yin Q, Linehan MM. A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers. J Afect Disord. 2018;232:219–28. [84] Wilks, C. R., Gurtovenko, K., Rebmann, K., Williamson, J., Lovell, J., & Wasil, A. R. (2021). A systematic review of dialectical behavior therapy mobile apps for content and usability. Borderline Personality Disorder and Emotion Dysregulation, 8(1). https://doi.org/10.1186/s40479-021-00167-5 [85] Xie, Q., Torous, J., & Goldberg, S. B. (2022). E-mental health for people with personality disorders: a systematic review. Current Psychiatry Reports, 24(10), 541–552. https://doi.org/10.1007/s11920-022-01360-1

Chapter 1 26 [86] Frías Á, Palma C, Salvador A, Aluco E, Navarro S, Farriols N, et al. B·RIGHT: usability and satisfaction with a mobile app for self-managing emotional crises in patients with borderline personality disorder. Australas Psychiatry. 2021;29(3):294–8. [87] van Leeuwen, H., Sinnaeve, R., Witteveen, U., Van Daele, T., Ossewaarde, L., Egger, J. I. M., & van den Bosch, L. M. C. (2021). Reviewing the availability, efficacy and clinical utility of telepsychology in dialectical behavior therapy (tele-dbt). Borderline Personality Disorder and Emotion Dysregulation, 8(1). https://doi. org/10.1186/s40479-021-00165-7 [88] Zalewski, M., Walton, C. J., Rizvi, S. L., White, A. W., Gamache Martin, C., O'Brien, J. R., & Dimeff, L. (2021). Lessons learned conducting dialectical behavior therapy via telehealth in the age of covid-19. Cognitive and Behavioral Practice, 28(4), 573–587. https://doi.org/10.1016/j.cbpra.2021.02.005 [89] C. LeRouge, J. Ma, S. Sneha, and K. Tolle, “User profiles and personas in the design and development of consumer health technologies”, Int J Med Inf, 82(11), 2013, pp. 251-268. [90] L. Van Velsen, L. Van Gemert-Pijnen, N. Nijland, D. Beaujean, and J. Van Steenbergen, “Personas: The linking pin in holistic design for eHealth”, The Fourth International Conference on eHealth, Telemedicine, and Social Medicine (eTELEMED 2012), IARIA, ISSN: 2308-4359, ISBN: 978-1-61208-179-3, pp. 128 – 133.

CHAPTER 2 Developing a Personalised Virtual Coach ‘Denk Je Zèlf!’ for Emotional Eaters through the Design of Emotion-Enriched Personas Aranka Dol, Olga Kulyk, Hugo Velthuijsen, Lisette van Gemert-Pijnen, Tatjana van Strien International Journal on Advances in Life Sciences, vol 8 no 3 & 4, year 2016 http://www.iariajournals.org/life_sciences/

30 Chapter 2 Abstract Obesity is a fast-growing societal threat, causing chronic conditions, physical and psychological health problems, as well as sickness absence and heavy healthcare costs. Despite numerous attempts to promote physical activity and healthy diet, existing interventions do not focus on the common emotional causes of obesity. There is a need for self-management support of this vulnerable target group: emotional eaters. This paper presents the results of the design case study focusing on a holistic design and evaluation of a personalised virtual mHealth coach that provides self-management training ‘Denk je zèlf!’ (Dutch for ‘Develop a wise mind and counsel yourself’). The target group are young adults with an emotional eating disorder and who are obese. The contextual inquiry study was conducted to gain insights into the needs and experiences of the target users, including interviews and questionnaires with emotional eaters, patients undergoing obesity treatment, and healthcare practitioners. Personas and the use-case scenario were derived from these results and translated into the new ‘Denk je zèlf!’ virtual coach, based on Dialectical Behaviour Therapy and experience sampling measures to capture user experience and emotional state. The main contributions of this paper are: (a) combining holistic eHealth design, behavior chain analysis, and dialectic behaviour therapy in one personalised virtual mHealth coaching application for emotional eaters; (b) applying emotion-enriched Personas to guide the design; (c) the results of the initial user evaluation. Preliminary results suggest that the ‘Denk je zèlf!’ virtual coach is useful for helping the target group. Future research will be aimed at further iterative (re)-design and evaluation, as well as development of the dialectical dialogues for the virtual coach and content for the education and instruction modules. Keywords: Obesity, emotional eating, Dialectical Behaviour Therapy, Persona, personalised care, virtual coach, persuasive design, young adults.

Developing a Personalized Virtual Coach for Emotional Eaters 31 2 Introduction The fast growth of obesity is a major threat to society. Treatment of obesity and obesityrelated conditions imposes a heavy societal burden due to high healthcare costs, reduction of life spans and increased risk of developing other chronic conditions such as diabetes, heart disease, osteoarthritis, and certain cancers [1-4]. Obese patients often suffer from psychological comorbidities, such as depression and low self-esteem [5]. Obesity is defined as an abnormal or excessive fat accumulation that may impair health and is classified as such by a Body Mass Index (BMI) of 30 kg/m2 or higher [6]. Nearly 50% of the Dutch population suffer from being overweight and 12% from obesity [5]. Obesity is associated with poor eating habits and lack of physical activity, unhealthy family lifestyle and low socio-economic status. Increasing physical activity and reducing food intake (dieting) are considered cornerstones in the prevention and treatment of obesity. However, though many of the existing interventions are successful and help patients lose weight in the short run, long-term randomised studies demonstrate that “diets are not the answer” [7]. Existing interventions and online weight loss programs, such as Weight Watchers [8], My Diet Coach [9] and Lose it! [10] focus primarily on the ‘Big Two’ aspects, namely: eat less, exercise more. They do not provide the necessary support in the long run, as people are unable to maintain their bodyweight over a longer period. Emotional eaters and obesity Recent studies have shown that a considerable group (40%) of the obese population overeat due to negative emotions [11]. Emotional eating is an atypical stress reaction. A normal reaction to stress and negative emotions would be loss a of the appetite. Emotional eaters show this atypical behaviour because they confuse negative emotions with hunger. They have a narrow view of what happens in their bodies (poor interoceptive awareness) and they are experiencing difficulties identifying and describing emotions and feelings (alexithymia). Emotional eaters are facing problems with emotion regulation – the ability to keep one’s emotional system in a healthy condition [12]. Diets and behaviour therapies do not help people with high degrees of emotional eating as they do not tackle the underlying emotional regulation difficulties, that lead to emotional eating [13-14]. Most emotional eaters have a long history of dieting, followed by the inevitable overeating and starting dieting again. They gain weight because of poor emotion regulation, not just due to poor eating habits or an insufficient level of physical activity [15]. Many times, they have tried to lose weight and when the emotional eating behaviour kicked in again, they ended up being heavier than when they started their previous

Chapter 2 32 dieting episode. This is an example of the so-called ‘yo-yo effect’ in health behaviour [16-17]. It is highly conceivable that this is the cause of an accumulation of disappointments and a growing lack of confidence that one will ever succeed. Emotional eaters and eHealth Evidence suggests that eHealth and Cognitive Behaviour Therapy can be just as effective as face-to-face treatments. Evidence-based therapeutic procedures can be delivered online [18]. In addition, emotional eaters need personalised anonymous support that is always available. Not only do emotional eaters need moral support, but a personalised self-management support could also clear away obstacles that keep emotional eaters away from face-to-face contact with a therapist. Obese emotional eaters form a particularly vulnerable group of people. To avoid further setbacks, they need support they can rely on, that is both trustworthy and promising, but realistic, and that matches with their needs. Such support needs to be accessible and comfortable so that one feels safe and secure. There is a need for supportive training programs for this specific target group of emotional eaters. This paper presents a design case study aimed at the development of a personalised virtual mHealth coach application for self-management support of young adult emotional eaters who are obese. The paper is structured as follows. In Related work, related work on online eHealth interventions for emotional eaters and obesity is discussed. Next, in Approach and Methods the approach and methods are presented for developing Personas and applying them to guide the design process. In Results the results are presented including a use case scenario and the first prototype of the ‘Denk je zèlf!’ virtual coach. Finally, a discussion and conclusions are presented in Conclusions and discussion. Related work Dialectical Behaviour Therapy Dialectical Behaviour Therapy (DBT) is a new way of treating emotional eating behaviour. DBT was originally designed to help people who are suffering from Borderline Personality Disorder [19]. The therapy focuses on the process of ‘reduction of ineffective action tendencies linked with dysregulated emotions’ [20]. Recent research into the deployment of Dialectical Behaviour Therapy shows positive results in weight loss management and weight maintenance in obese emotional eaters [13]. DBT might be successful in patients where insufficient progress was achieved using Cognitive Behavioural Therapy (CBT) [12,

Developing a Personalized Virtual Coach for Emotional Eaters 33 2 21-22]. Currently, CBT is considered the state-of-the-art in treating eating disorders, aimed at treating eating disorders such as Boulimia Nervosa (BN), Anorexia Nervosa (AN) and Eating Disorders Not Otherwise Specified (EDNOS). The core of these eating disorders is the patient’s over-evaluation of his control of weight, shape and/or eating. The efficacy of DBT for the treatment of Binge Eating Disorder (BED) and emotional eating behaviour has been demonstrated in the results of various studies and trials [23-26]. The dialectical focus One of the most powerful ‘mechanisms of change’ or mediators in DBT is its dialectical focus. Since an invalidating environment plays an important role in the lives of emotional eaters, it is important that they are treated with a well-balanced mix of being validated in their perception of negative emotions and being confronted with a practical focus on changing problem behaviour. “Based in the biosocial theory, DBT has a unique approach to targeting behavioural dysfunction that is not typically seen among other cognitivebehavioural treatments; one key difference is the emphasis placed on emotions and emotion dysregulation.” [20]. DBT and eHealth There is a broad variety of eHealth self-management treatments available but the majority focus on weight loss and behaviour change. The discussion on the effectiveness of such interventions is progressing only slowly [27-33]. Little knowledge in the field of eHealth treatment using Dialectical Behaviour Therapy or even emotion regulation has been acquired so far, let alone about emotion regulation focused on emotional eating behaviour. The results of one quasi-experimental study on the effectiveness of the mobile “DBT Coach”, that focused only on one particular skill in DBT (Opposite Action), showed that emotion intensity decreased within each coaching session in participants suffering fromBorderline Personality Disorder [34-35]. The target group uses the DBT Coach when it is needed most for them – after engaging in dysfunctional behaviour. One paper discusses the lack of user-friendliness of a DBT self-management mHealth application [36]. A small number of DBT-based self-management mHealth apps can be found in the Google Play Store and in the Apple App Store. However, they typically lack scientific grounding, user involvement in the design process, psychological aspects, and personalization. Virtual coach and behaviour change Substantial research has been dedicated to the employment of virtual coaches [37-38]. A virtual coach, as an interactive and self-learning persuasive system, can assist in attitude and/or long term behaviour change by providing immediate and personalised support

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