Table 2. Means and standard deviations for all variables at all four time points (participants who completed all follow ups).

completed all four anxiety measures. Results indicated no between groups differences on baseline measures between anxiety completers and non-completers for the following: power of food (p = .359), restraint (p = .595), somatic symptoms (p = .597), depression (p = .967), anxiety (p = .356), weight (p = .506), or BMI (p = .151). A difference was detected between anxiety completers and non-completers for food cravings (t (361) = 2.39, p = .043). Anxiety completers having lower food cravings (M = 75.57, SD = 22.36) than anxiety non-completers (M = 81.41, SD = 20.12).

To further investigate attrition a series of t-tests were run on baseline measures to investigate differences between completers and non-completers. For the in-person group, results indicated no significant differences across baseline measures: food cravings (p = .239), power of food (p = .447), restraint (p = .894), somatic symptoms (p = .245), depression (p = .468), anxiety (p = .633), weight (p = .834) and BMI (p = .734). For the online group there were no significant differences observed at baseline between completers and non-completers for food cravings (p = .165), power of food (p = .565), restraint (p = .104), or somatic symptoms (p = .524). There were significant differences between observed at baseline for depression (t (299.17) = .638, p < .001), anxiety (t (242) = 2.31 p = .022), weight (t (307) = 3.17, p = .002) and BMI (t (302) = 3.18, p = .002). In the online condition the non-completers reported higher levels of anxiety (M = 7.53, SD = 3.42), depression (M = 10.12, SD = 6.20), weight (M = 92.59 SD = 19.01) and BMI (M = 34.02, SD = 6.49), than the completers (anxiety M = 6.54, SD = 3.09; depression M = 7.63, SD = 5.00; weight M = 85.82 SD = 16.96; BMI M = 31.73, SD = 5.67).

3.2. Main Analysis

Eight mixed factorial repeated measures ANOVAs (food cravings, power of food, restraint, anxiety, depression, somatic symptoms, BMI and weight) were conducted to determine whether there were statistically significant differences (p < .05) between in-person and online treatment groups following an eight-week intervention across four time points (pre, post, six-month and twelve-month).

Levene’s test indicated that the assumption of homogeneity of variance was met for food cravings, weight and BMI; however, it was violated for power of food, restraint, somatic symptoms, depression and anxiety. In each case of a violation the ANOVA was repeated with equal groups by selecting a random sample from the online group equal in size to the in-person group (Stevens, 2002).

In sum, both modalities were comparable in efficacy and experienced significant reductions from pre-intervention to post-intervention, with reductions remaining significant at follow ups for food cravings, power of food, depression and weight, with minor differences observed at post-intervention or 6-month follow up for dietary restraint, somatic symptoms, anxiety and body mass index. Follow-up analyses revealed a significant effect of depression, anxiety and weight on attrition in the online treatment group. Each are now outlined in depth.

3.2.1. Food Cravings

Mauchly’s test of sphericity indicated that the assumption of sphericity had been violated, χ2 (5) = 40.00, p < .001, therefore a Greenhouse-Geisser correction was applied (ε = 0.842). The mixed factorial ANOVA revealed a significant main effect for Time, F (2.53, 383.89) = 42.61, p < .001, partial η2 = .22. A priori pairwise comparisons across both groups conducted with a Sidak correction revealed that food cravings decreased from pre-intervention. There were significant between-group differences prior to the intervention, which remained consistent after treatment (F (1, 152) = 27.07, p < .001, partial η2 = .15); however, no interaction was found between time and treatment condition F (2.53, 383.89) = 2.49, p = .072, partial η2 = .016. Pairwise comparisons indicated a significant decrease for food cravings pre and post (p < .001), being maintained at the six and twelve month follow ups.

Combined groups experienced a 23% reduction in food cravings (see Table 2) from pre-intervention to post intervention, which remained consistent at the 12 month follow up.

3.2.2. Power of Food

Mauchly’s test indicated that the assumption of sphericity had been violated, χ2 (5) = 23.037, p < .001, therefore a Greenhouse-Geisser correction was applied (ε = 0.910). The mixed factorial ANOVA revealed a significant main effect for Time, F (2.73, 415.15) = 50.49, p < .001, partial η2 = .25. Pairwise comparisons revealed significant reductions pre- to post-treatment (p < .001) and remained stable from post-intervention to both 6- and 12-months. Scores from post- to 6- and 12-months were not significantly reduced, nor between 6 and 12 months F (1, 152) = .17, p = .683. No interaction was found between Time and Treatment Condition F (2.73, 415.15) = .038, p = .986.

Combined groups experienced a 23.5% reduction in power of food from pre-intervention to post intervention, increasing to an overall 27% reduction from pre-intervention to 12 months.

3.2.3. Restraint

Mauchly’s test revealed that the assumption of sphericity had been violated, χ2 (5) = 64.801, p < .001, therefore, a Greenhouse-Geisser correction was applied (ε = 0.782). The mixed factorial ANOVA revealed a significant main effect of Time, F (2.35, 356.72) = 42.06, p < .001, partial η2 = .22. Pairwise comparisons revealed scores had significantly improved pre- to post-intervention (p < .001) and continued to improve from post to 6 months (p = .003), and from 6 months to 12 months (p < .001). No significant main effect of treatment condition was observed, F (1, 152) = 1.62, p = .206. A significant interaction was found between Time and Treatment Condition, F (2.35, 356.72) =10.70, p < .001, partial η2 = .07. For the equal sized groups ANOVA the interaction effect between Time and Treatment condition became non-significant due to the lack of power (p = .084). Post hoc analysis of the unequal groups significant interaction investigated the differences between the groups at each time point to determine at what point across the four time points the groups differed. The groups did not differ at pre, post or at the six-month time point; however, at twelve-months the online group scores stabilised, while the in-person group scores continued to decline.

Combined groups experienced a 6% improvement in restraint from pre-intervention to post intervention, with an overall 14% improvement observed from pre-intervention to 12 months.

3.2.4. Somatic Symptoms

Mauchly’s test of sphericity indicated that the assumption of sphericity had been violated, χ2 (5) = 27.724, p < .001, therefore, a Greenhouse-Geisser correction was applied (ε = 0.904). The mixed factorial ANOVA revealed a significant main effect for Time, F (2.71, 406.95) = 7.66, p < .001, partial η2 = .05. Pairwise comparisons revealed that somatic symptoms were significantly lowered from pre- to post-intervention (p < .001) and remained stable from post- to 6-months (p = .128); however, a statistically significant decrease was observed between 6- to 12-months (p = .048). No significant main effect of treatment condition was observed, F (1, 150) = 3.09, p = .081. A significant interaction was found between Time and Treatment Condition, F (2.71, 406.95) =3.40, p = .021, partial η2 = .022. Post hoc analysis of the unequal groups significant interaction investigated the differences between the groups at each time point to determine at what point across the four time points the groups differed. The groups did not differ at pre, post or at the twelve-month time point; however, at six-months the online group scores remained lower than pre-intervention while the in-person group scores had increased to pre-intervention levels, before returning at 12-months to post-intervention levels. For the equal sized groups ANOVA the interaction effect between Time and Treatment condition disappeared due to the lack of power (p = .080), and an effect of Treatment condition was observed, F (1, 53) = 5.59, p = .022, partial η2 = .10.

Combined groups experienced a 23% reduction in somatic symptoms from pre-intervention to post intervention, with an overall 29% reduction from pre-intervention to 12 months.

3.2.5. Depressive Symptomology

The mixed factorial ANOVA revealed a significant main effect for Time, F (3, 453) = 10.99, p < .001, partial η2 = .07. Pairwise comparisons revealed that depressive symptoms were significantly decreased from pre-intervention to immediately post-intervention, from pre-intervention to 6-months following intervention (p < .001), and from pre-intervention to 12 months following intervention (p = .001). There was no significant difference observed in participants’ depressive symptomatology from post-intervention to either 6 months or 12 months, nor between 6 and 12 months. No significant main effect of treatment condition was observed, F (1, 151) = .14, p = .707. No significant interaction was found between Time and Treatment Condition, F (3, 453) = 0.21, p = .887.

Combined groups experienced a 33% reduction in depressive symptoms from pre-intervention to post intervention, with an overall 25% reduction observed from pre-intervention to the 12 months.

3.2.6. Anxious Symptomology

The mixed factorial ANOVA revealed a significant main effect for Time, F (3, 177) = 17.331, p < .001, partial η2 = .23. Pairwise comparisons revealed that anxious symptoms were not significantly decreased from pre- to post-intervention (p = .137). However, there was a statistically significant difference observed in participants’ depressive symptomatology from post- to 6-months (p = .004), and between post- to 12-months’ follow-up (p < .001), and between the 6 and 12 month follow up (p = .025). A significant main effect of treatment condition was observed, F (1, 59) = 4.78, p = .033, partial η2 = .08. A significant interaction was found between Time and Treatment Condition, F (3, 177) = 3.30, p = .022, partial η2 = .05. Preliminary analysis had highlighted the between groups difference of anxiety prior to the intervention; although, this does not explain the interaction. Post hoc analysis investigated the differences between groups at each time point revealed that the in-person group’s anxiety was increased immediately post intervention, while for the online group it was reduced. The online group’s scores then remained stable between post-intervention and 6 months, while between 6 and 12 months it reduced further. For the in-person group anxiety levels were reduced between post intervention and the 6 month follow up, and reduced even further by 12 months.

Combined groups experienced a 11% reduction in anxious symptoms from pre-intervention to post intervention, with an overall 48% reduction from pre-intervention to the 12 months.

3.2.7. Weight

For participants’ weight, Mauchly’s test indicated that the assumption of sphericity had been violated, χ2 (5) = 152.60, p < .001, therefore, a Greenhouse-Geisser correction was applied (ε = .608). The mixed factorial ANOVA revealed a significant main effect for Time, F (1.83, 262.78) = 12.13, p < .001, partial η2 = .08. Pairwise comparisons revealed that between pre- and post-intervention there was no significant effect of treatment on weight (p = .078). However, there was a significant difference between post-intervention scores and the 6-month follow (p < .001), and between post intervention and-12 months (p = .001). There was no significant difference between 6 and 12 months (p = .488). There was no significant effect of Treatment Condition, F (1, 144) = 1.31, p = .254). There was significant interaction observed between Time and Treatment Condition, F (1.83, 262.76) = 2.70, p =.074.

Both groups combined experienced a 1% reduction in weight from pre to post intervention, and an overall reduction of 3% from pre-intervention to 12 months.

3.2.8. BMI

Mauchly’s test indicated that the assumption of sphericity had been violated, (χ2 (5) = 142.85, p < .001), therefore a Greenhouse-Geisser correction was applied (ε = 0.616). The mixed factorial ANOVA revealed a significant main effect of Time, F (1.85, 264.28) = 18.11, p < .001, partial η2 = .11. Pairwise comparisons revealed that BMI pre was statistically and significantly decreased at post (p = .007); was significantly decreased between pre-intervention and 6 months (p < .001), and between pre-intervention and 12 months (p < .001). There was a significant reduction between post-intervention and 6 months (p < .001) and between post-intervention and 12 months (p < .001). There was no significant difference between 6 and 12 months (p = .485). There was no significant main effect of Treatment Condition, F (1, 143) = 0.68, p =.410; however, there was a significant interaction observed between Time and Treatment Condition, F (1.85, 264.28) = 5.63, p = .005, partial η2 = .04. At the 6 and 12-month follow up the in-person groups’ scores decline more dramatically than the online group scores suggesting that there was a greater impact on BMI for the in-person group than the online group.

Combined groups experienced a 1% reduction in BMI from pre-intervention to post intervention, with an overall reduction of 3.5% from pre-intervention to 12 months.

4. Discussion

Recent research has supported the application of a novel intervention, EFT, to address the internal psychological determinants affecting food choices and weight gain via an in-person format (Church & Brooks, 2010; Stapleton, Sheldon, & Porter, 2012; Stapleton, Bannatyne, Porter, Urzi, & Sheldon, 2016), and more recently as an online intervention (Church & Brooks, 2010; Church & Wilde, 2013; Stapleton et al., 2012, 2016, 2019). To date no study has explored whether these two modalities are equivalent in efficacy, or whether an online or in-person mode of treatment is more efficacious than the other.

Despite a between groups difference for food cravings at pre-intervention, both groups experienced a similar reduction from pre to post intervention, which was maintained at the 6 and 12-month follow up and no interaction between groups was observed. Both groups experienced a significant reduction from pre to post-intervention, with these results remaining stable at the 6 and 12-month follow up. Dietary restraint scores improved from pre to post intervention, and continued to improve for both groups between post-intervention and 6 months and for the in-person group between 6 and 12 months.

Both groups also experienced a significant reduction in weight from pre to 6 months, and pre-intervention to 12-months. The mean weight loss for the online group from pre-intervention to 12 months was 2.39 kilograms (1.5%) while for the in-person group it was slightly higher at 3.83 kilograms (4%). There were no significant between group differences in total weight lost, although the interaction was approaching significance (p = .074) suggesting that with a larger sample size an interaction between treatment condition and time may have been observed.

The online and in-person groups achieved a significant effect of treatment; however, the results insinuate that there may be a stronger effect of treatment on weight for in-person therapy than for online therapy. Differences in weight between completers and non-completers within the online group indicated that the average weight at baseline of participants who did not complete all follow ups compared was 6.77 kilograms heavier than completers. These findings support research which suggests a relationship between weight and attrition (Teixeira et al., 2004).

For depression both groups experienced a significant effect of time with scores reducing from pre to post intervention and remaining stable at 6 and 12 months. For somatic symptoms both groups did experience an overall reduction in the level of symptoms by the 12 month follow up; however, the effect was different at 6 months when the in-person group experienced a rise in levels of symptoms, before they reduced again at 12 months. The online group experienced a greater overall reduction in somatic symptoms from pre-intervention to 12 months (31.5%) than the in-person group (16%).

For anxiety both groups experienced a decrease in symptoms from pre-intervention to the 6 and 12-month follow up; however, once again a differential effect across time was observed between groups. Symptoms of anxiety for the in-person group initially increased from pre intervention to post intervention before declining with an overall reduction of 53% observed from baseline at the 12 month follow up. The online groups’ scores decreased from pre to post intervention, remained stable at the 6-month follow up and continued to decline from 6 to 12 months with an overall reduction of 46% from baseline. The initial increase in anxiety at post-intervention for the in-person group could suggest that participating in an in-person treatment group can initially increase the experience of anxiety. This is consistent with research that suggests a particular benefit of online treatment for anxiety is the elimination of situational stress elicited by face-to-face interventions (Berger et al., 2014).

Results of the analysis between the completers and non-completers revealed a significant between groups difference in pre-intervention levels of depression and anxiety, which is consistent with existing research indicating a strong relationship between attrition, anxiety and depression (Fabricatore et al., 2009; Honas et al., 2003; McLean et al., 2016). The fact that this was only observed in the online group is compatible with studies that propose that the presence of anxiety and depression can cause higher rates of attrition for online therapy programs (Christensen et al., 2009). Differences between the non-completers in the online group on the variable of weight was also consistent with research suggesting that higher rates of obesity are correlated with increased likelihood of attrition, and increased likelihood of comorbid psychological disorders (Bodenlos et al., 2011; Gariepy et al., 2010; Luppino et al., 2010; McLean et al., 2016). These findings highlight the importance of identifying these high risk clients in order to offer targeted assistance for their depression and anxiety to enhance program adherence.

5. Conclusion

While this is the first study comparing online EFT with in-person EFT, replication studies using larger sample sizes, particularly for the in-person condition, are recommended. The current study had a low number of males, although the overrepresentation of females is consistent with research into emotional eating (Zellner et al., 2006). A further limitation is that the in-person group was selected under a specific exclusion criterion, while the online group participants self-selected their inclusion. The cost of in-person treatment often makes the selection process a necessary pre-requisite for admittance to an in-person program, while for an online program greater numbers can be catered to. Future research would benefit from the same inclusion and exclusion criteria. Finally, the lack of an online comparison treatment group presents another limitation of the current study.

Overall, the findings of the present study suggest that both modalities are equally efficacious in reducing overall levels of food cravings, the subjective power of food, levels of restraint, weight and BMI, as well as, lowering rates of anxiety, depression and somatic symptoms. There were some between groups’ differences in the action of the treatment condition in effecting these changes, and the in-person group appeared to have achieved a slightly greater effect of weight loss, while the online group experienced greater effects for the treatment of somatic symptoms.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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