INTRODUCTION AND BACKGROUND
Eating disorders are a global health problem. Female adolescents and young women are most at risk of developing these conditions, characterised by significant disturbances in eating habits or weight-control behaviour resulting in a clinically significant impairment of physical or psychosocial functioning (Fairburn & Harrison, 2003). They are amongst the most serious psychiatric disorders (Klump, Bulik, Kaye, Treasure, & Tyson, 2009) and can cause substantial morbidity and mortality. In a meta-analysis of research into the mortality of mental disorders in the 1990s, eating disorders were shown to have the highest risk of premature death from both natural and unnatural causes (Harris & Barraclough, 1998). Death from suicide and complications are common amongst individuals with anorexia nervosa (Millar et al., 2005; Sullivan, 1995). The major complications include cardiac arrhythmia, metabolic disturbance, electrolyte imbalance, hypoglycaemia, dehydration, and renal failure.
Eating disorders often become a chronic illness with a significant effect on individuals' quality of life. The severity and chronic nature of the illness exert negative effects on various life domains such as physical functioning, employment, finances, interpersonal relationships, and social and role functioning (Herzog, Norman, Rigotti, & Pepose, 1986; Mitchell, Hatsukami, Eckert, & Pyle, 1985). Sufferers of eating disorders report more impaired quality of life than those with other psychiatric disorders (e.g., alcohol abuse and somatoform disorder) and physical illnesses (e.g., angina and cystic fibrosis), even after recovery of symptoms (Jenkins, Hoste, Meyer, & Blissett, 2011; Spitzer et al., 1995).
The treatment of eating disorders is complex and expensive. Sufferers have little access to treatment (Hoek & van Hoeken, 2003), and the obstacles to treatment may be related to shame, guilt, denial, fear of stigmatisation, poor motivation to change, geographical isolation, inadequate health care resources, and unaffordable treatment. Shame and stigma can encourage individuals with eating disorders to avoid or postpone treatment (Becker, Arrindell, Perloe, Fay, & Striegel-Moore, 2010). Poor motivation often leads to low volition to engage in treatment (Darcy et al., 2010). The geographical and financial constraints on individuals can impede their access to care (Becker et al., 2010; Cachelin et al., 2001). Internet-based intervention offers a valuable opportunity to enable wider access to healthcare services, improve sufferers' self-management and enhance health outcomes (Forkner-Dunn, 2003). This intervention approach may best suit the needs of individuals with eating disorders by reducing their resistance to treatment, improving their access to service at a low cost and engaging them in their own care.
Studies have examined the efficacy of Internetbased self-help approaches for the treatment of bulimia nervosa in several European countries, including Germany, Switzerland, Sweden and Spain (Carrard et al., 2006, 2011; Liwowsky, Cebulla, & Fichter 2006; Ljotsson et al., 2007; Nevonen, Mark, Levin, Lindström, & Paulson- Karlsson, 2006). The findings of these studies indicate that Internet-based self-help programmes can improve the severity of symptoms, general psychopathology, depression, self-esteem, and general life satisfaction. Treated individuals show a significant reduction in dietary restraint, weight phobia, bingeing, self-induced vomiting, and excessive physical activity (Carrard et al., 2011; Ljotsson et al., 2007; Nevonen et al., 2006). The results of these studies on Internet-based self-help programmes are encouraging, and this innovative therapy approach could be expanded in the Asia-Pacific region for the treatment of eating disorders. Cognitive-behavioral therapy approach has been used in various Internetbased interventions conducted in European countries and many are found to be effective to improve symptoms of eating disorders such as binge eating and self-induced vomiting (Ljotsson et al. …