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									                                                   Blackwell Publishing LtdOxford, UKOBRObesity Reviews1467-7881© 2007 The Authors; Journal compilation © 2007 The International Association for the Study of Obesity 85459465
                                                                                                                                                                                                                    2007

                                                   Review ArticlesInternet for weight lossS. L. Saperstein et al.




obesity reviews                                                                                                                                                    doi: 10.1111/j.1467-789X.2007.00374.x




The impact of Internet use for weight loss

S. L. Saperstein1, N. L. Atkinson1 and R. S. Gold2


1
    Department of Public and Community Health,              Summary
Public Health Informatics Research Laboratory,              With rising rates of obesity and obesity-related health problems, finding additional
University of Maryland, 2College of Health and              means to help reduce obesity is critical. This review examined the impact of the
Human Performance, University of Maryland,                  Internet as a medium to deliver weight loss programs. Specifically, the review
College Park, MD, USA                                       examined the public’s interest, the availability and the known efficacy of Internet-
                                                            based weight loss programs. Findings showed that the general public is turning
Received 9 November 2006; revised 23                        to the Internet for diet and fitness information and has reported that information
January 2007; accepted 9 February 2007                      they found online has impacted their behaviour. Little is known about who is
                                                            interested in using the Internet for weight loss and what their experiences have
Address for correspondence: SL Saperstein,                  been. The programs most readily available to the general consumer tend to vary
Department of Public and Community Health,                  widely in quality, with few efficacy studies. However, researchers have shown that
Public Health Informatics Research Laboratory,              efficacious programs have been delivered via the Internet. Successful online pro-
Suite 2387 Valley Drive, University of Maryland,            grams included a structured approach to modifying energy balance, the use of
College Park, MD 20742-2611, USA. E-mail:                   cognitive-behavioural strategies such as self-monitoring, and individualized feed-
ssaperst@umd.edu                                            back and support. Implications include developing strategies to increase distribu-
                                                            tion of programs with known efficacy, determining the applicability of effective
                                                            programs for diverse audiences, conducting media literacy education for the
                                                            general public, and continued research into understanding who may be best served
                                                            by online weight loss programming.

                                                            Keywords: Internet, obesity, online, weight loss.

                                                            obesity reviews (2007) 8, 459–465




                                                                                                                       A growing body of evidence has shown the positive
Introduction
                                                                                                                    effects of computer- and Internet-based programs on a
The purpose of this review is to examine whether the                                                                range of health behaviours (6). Internet-based programs
Internet is a viable medium through which to deliver weight                                                         can provide opportunities for interactivity and active par-
loss programs. Sixty-six per cent of American adults are                                                            ticipation (6). They are available anytime, provide anonym-
either overweight or obese (1). Because of the known                                                                ity to those who might not want to seek face-to-face
multitude of obesity-related health problems that can be                                                            treatment, and reduce travel barriers (7). Further, they can
reduced by a weight loss of just 5–15% of body weight (2),                                                          combine the advantages of an individualized approach with
finding additional means to help reduce obesity is critical.                                                         the potential to reach large numbers of people (8). Tailoring
   Americans have not been passive in their response to the                                                         involves collecting individual-level data, which is then used
growing obesity epidemic. Millions of Americans have been                                                           to customize health materials to an individual’s unique
trying to lose weight at any one time (3). In 2000, 46% of                                                          needs (9). Tailored information delivered over the Internet
American women and 33% of American men reported                                                                     or computer has been shown to positively impact health
trying to lose weight (4). Numerous organized programs,                                                             knowledge and behaviours (10) and to be more satisfying,
both commercial and self-help, exist to help people lose                                                            more personally relevant, read more deeply, and more often
weight (3,5), and Internet-based programs represent a new                                                           discussed with others (11). The Internet also affords a
medium for program delivery (5).                                                                                    means of giving and receiving social support and sharing


© 2007 The Authors
Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465                                                                                                          459
460   Internet for weight loss   S. L. Saperstein et al.                                                                obesity reviews


information and personal experiences with others through
                                                                           Is the general public interested in online weight
participation in online communities (12).
                                                                           loss programs?
   The Internet is not without disadvantages. Because using
the Internet is a sedentary activity, it may seem paradoxical              About 95 million Americans have searched for health infor-
to think it could be a valuable tool for weight loss. Simi-                mation online (17), and the number of users looking for
larly, its benefit of reducing travel to and from an in-person              nutrition and exercise information is on the rise. Fifty-one
session could result in less physical activity for some. Sitting           per cent of Internet users reported going online for diet and
at the computer is sedentary, but so is reading text-based                 nutrition information in 2004, as compared with 44% in
information in brochures or sitting in a support group.                    2002 (17). A similar increase was seen in the search for
   Thus, using the Internet is no more sedentary than tra-                 information about physical activity, with 42% of respon-
ditional forms of communication, but it can offer tremen-                  dents in 2004 reporting that they searched online for
dous potential for increasing a user’s motivation to modify                exercise and fitness information as compared with 36% in
diet and physical activity through its interactive features,               2002 (17).
hints and strategies for overcoming barriers, and opportu-                    In 2004, Nielsen ratings showed that eDiets and Weight
nities to share support and encouragement with others.                     Watchers were the two most visited health, fitness and
Additionally, materials can be distributed over the Internet               nutrition websites (18). According to the eDiets website,
at a far lower cost than print materials, and its multimedia               over 2 million eDiets memberships had been purchased
capabilities surpass what can be offered in print (13). For                since 1997 (19). In 2006, eDiets and Weight Watchers
example, online video can provide instruction on how to                    were still among the top 10 of the most visited health
correctly perform certain physical activities, thus reducing               websites (20).
risk of injury and increasing likelihood of continued                         Thirty per cent of successful Internet users who searched
engagement in that activity.                                               for this information reported that the information they
   Although more people have access to the Internet, the                   found changed the way they thought about diet, exercise
‘digital divide’ issue, particularly for access to broadband,              and stress (21). Many Internet users reported that the
high-speed connections still exists (6,14). Some groups with               online information they read had directly affected decisions
higher rates of overweight and obesity have lower rates of                 they made about health care, interactions they had with
Internet use, and these non-users may be at the greatest                   their doctors and how they cared for themselves (22).
health risk (14). Literacy, language, cultural and ability                    Two smaller studies have shown the potential range of
barriers may additionally keep people from accessing                       interest in the Internet for behaviour change assistance.
health tools on the Internet (6). However, recent findings                  Sciamanna et al. (23) surveyed 300 primary care patients
show that Internet use is increasing in all segments of the                about their interest and experience in using the Internet for
population (15). Broadband adoption grew by 40% in                         health-related activities. Of the two-thirds with Internet
2005, with strong adoption rated observed among minority                   access, 52.6% reported an interest in using the Internet to
groups and those with less than a high school educa-                       assist in making lifestyle changes, and 46.6% reported that
tion (15).                                                                 they had already used the Internet for this purpose. Cum-
   This review will focus on programs delivered over the                   mins et al. (8) surveyed adult Internet users with specific
Internet because of their potential to reach large numbers                 health risk behaviours (n = 375) who were recruited from
of people. In order to improve the delivery of health pro-                 a purchased list of Internet users and through employers.
motion programs on the Internet, research is needed that                   At baseline, only about one-quarter of survey respondents
will examine the population impact of online programs                      used the Internet for health behaviour change or disease
(16). Impact can be described as the combination of par-                   management programs. The majority of respondents
ticipation and effectiveness, which leads to a two-pronged                 reported no intention of starting to use such programs in
approach of identifying who is interested in using the Inter-              the future. A 1-year follow-up survey found that the major-
net for health promotion as well as examining the types                    ity who were using Internet-based health behaviour change
and quality of available online programs (16).                             programs at baseline were no longer using them at
   The aim of this paper is to examine the potential of the                follow-up.
Internet as a medium to facilitate weight loss. This review                   Differences in the results of these two studies could be
will explore the following questions: (i) Is the general pub-              due to methodology and sampling differences. Sciamanna
lic interested in using online weight loss programs? (ii)                  et al. (23) used a more restrictive definition of online health
What will the general public find when they go online for                   behaviour change programs, which could account for their
weight loss? and (iii) What is the known efficacy of online                 lower percentage of positive responders. Additionally, the
programs designed to promote weight loss? Findings from                    sample from the study by Sciamanna et al. (23) was
this review have implications for practitioners and future                 selected from primary care practices in Rhode Island, while
research.                                                                  sample in the study by Cummins et al. (8) was recruited


                                                                                                                                     © 2007 The Authors
                                           Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465
obesity reviews                                                                                Internet for weight loss   S. L. Saperstein et al.   461




from 30 states. The former sample (23) also had a higher                          need to understand who may be best served by Internet
percentage of women (83% vs. 62%) but a lower percent-                            programming and whether current programs are appropri-
age of respondents with a college degree (21% vs. 74%).                           ate for diverse users
Further research about experience with and readiness
to use Internet-based programs could help clarify these
                                                                                  What will the general public find when they go
differences.
                                                                                  online for weight loss?
   Little is known about actual uptake and use of specific
e-health tools in the public domain, especially in relation                       Analyses of websites providing behaviour change and
to who is using specific online tools, who might be influ-                          weight loss content to the general public have found
enced to try online tools, and the ability of the interested                      offerings of mixed quality. In one study, a set of screening
consumer to locate and access quality e-health tools (10).                        criteria was developed to evaluate whether behaviour
Although increasing numbers of people go online for diet                          change websites met a minimum criteria for having the
and exercise information and report that this information                         potential to produce behaviour change (29). A total of 294
impacts how they take care of themselves, we do not know                          websites addressing seven health behaviours (alcohol use,
much about their actual experiences especially with respect                       diet, exercise, smoking and management of asthma, depres-
to online weight loss sites. We do not know if users were                         sion, or diabetes) were critiqued with respect to their ability
satisfied with what they found online, how they judged                             to assess, advise, assist, provide anticipatory guidance and
credibility of sites, or if their online activities resulted in                   arrange follow-up. Only 15 sites met four or more of these
measurable behavioural changes, weight loss, or improve-                          criteria, indicating that most sites available to consumers
ment in health status.                                                            do not possess the minimum criteria needed to facilitate
   We also do not know much about what factors may                                behaviour change.
make a person more likely to want to use the Internet for                            In an examination of the first 50 websites found on an
weight loss. Three studies (7,24,25) found differential login                     Internet search using the Excite search engine with the
rates among participants using websites readily available                         search term ‘weight loss diets’, Miles et al. (30) found that
on the Internet. These studies also found that those who                          only three offered sound dietary advice, while 26 sites
logged in more frequently showed better weight loss. No                           offered the sale of vitamins, minerals, herbal supplements
analysis was performed to determine what factors differen-                        and diet replacements. They concluded that the informa-
tiated frequent users from infrequent users. In a pilot study                     tion available to those looking on the Internet ranged from
of an online weight maintenance program, Harvey-Berino                            sound advice to information that was potentially mislead-
et al. (26) found that only 9% of participants in an in-                          ing and dangerous. Tate et al. (31) examined weight loss
person therapist-led group thought they might have pre-                           websites as part of the developmental research for their
ferred an Internet-based group, while about half of the                           online programs. They found that, although the online sites
participants in the Internet-based group thought they                             contained much of the content of traditional behavioural
would have performed better if they had an in-person                              weight loss programs, they lacked the programmatic
group. In their next study (27), 70% of participants in the                       nature, structure and professional contact that were a
Internet-based group reported that they would prefer an in-                       critical part of in-person programs.
person support group, while only 40% of those in the in-                             A recent report by Consumer Reports WebWatch and the
person group reported preference for an online group. In a                        Health Improvement Institute (20) evaluated the 20 most
recent review of online programs with weight loss compo-                          trafficked diet websites for quality. Ratings were based on
nents, Weinstein (28) reported that most studies have been                        composite scores of site credibility, information quality and
conducted with participants who were educated and white,                          reliability, and ease of use. Eight sites with diet self-help
making it difficult to apply findings to other demographic                          components were also evaluated on the characteristics of
groups.                                                                           the diet plans. The diet self-help component was rated as
   These studies showed that people appear to be actively                         ‘very good’ on only WebMD, ‘good’ on five sites including
using the Internet for information on diet and physical                           eDiets and Weight Watchers, ‘fair’ on Light ‘n Fit, and
activity. Less is known about the actual impact and health                        ‘poor’ on TrimLife. No diet self-help component received
benefits of this online use. Some studies indicated that                           an ‘excellent’ rating.
people used weight loss sites at different frequencies, which                        The studies and reports reviewed in this section have
ultimately affected their weight loss. Other studies showed                       found behaviour change and weight loss websites to be
that some people might prefer other forms of intervention,                        uneven in their content and potential benefits. People who
rather than via the Internet. Because most studies of Inter-                      are interested in using the Internet for weight loss will need
net-based interventions have used primarily educated,                             to be savvy searchers who can identify credible and trust-
white participants, we do not know the interest levels of                         worthy sites from those less so. Rigorous evaluation of
other demographic groups. These findings underscore the                            whether these readily available sites can help users lose


© 2007 The Authors
Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465
462   Internet for weight loss   S. L. Saperstein et al.                                                                obesity reviews


weight is lacking, with the exception of three studies that                was compared with a more structured, personalized online
will be discussed in the next section.                                     program, V-Trim (24), the V-Trim participants lost twice
                                                                           as much weight as the eDiet participants. A third study (25)
                                                                           found that the Internet-based behavioural weight loss
What is the efficacy of Internet-based weight
                                                                           programs that included personalized feedback used by
loss programs?
                                                                           their intervention groups led to better weight loss than the
A literature review was undertaken to determine the effi-                   Slimfast.com program, which does not provide tailored
cacy of online weight loss programs. Studies were located                  feedback.
using combinations of the search terms ‘Internet’, ‘com-                      Self-report of outcomes can be biased, and people
puter’, ‘online’, ‘program evaluation’, ‘intervention studies’             often under-report their weight. A strength of the studies
and ‘weight loss’ in the PubMed, PsycINFO and CINAHL                       reviewed in this section is a reliance on objective data. In
databases. Studies were included if they reported the results              five of the six studies (7,24,25,31,32), participants were
of randomized controlled trials of Internet-based programs                 weighed and measured by staff in a clinic setting. However,
primarily designed for weight loss in overweight or obese                  as Womble et al. (7) pointed out, this in-person weighing
adults. Studies were excluded if they did not include an                   may have increased the participants’ sense of responsibility
Internet-based program primarily designed for weight loss,                 or accountability towards the study. Because of this, they
they were designed for weight loss maintenance or preven-                  concluded that their results might represent a best-case
tion of weight gain, or the intervention was for children.                 scenario. Similarly, self-report of food intake and physical
As the field is relatively new, a report of a randomized                    activity can also be biased. Tate et al. (31) found that
controlled trial that appeared in the 2006 Proceedings of                  participants in both their intervention and control groups
the Sixth Annual eHealth Developers’ Summit (24) and met                   reported similar changes in diet and exercise behaviour
review criteria was also included.                                         during the study; however, the intervention group lost
   Six randomized controlled trials met study inclusion cri-               significantly more weight. The researchers concluded
teria. Three studies examined readily available commercial                 that accurately assessing these behaviours is difficult. They
websites: the eDiets.com website was studied in two cases                  believed the intervention group probably became more
and the Slimfast.com website in the third. See Table 1 for                 accurate in their assessment because they were actually self-
an overview of the included studies.                                       monitoring these behaviours throughout the course of the
   Five (13,24,25,31,32) of the six studies showed that                    intervention and not just during the study assessments.
weight loss programs could be effectively delivered over the                  The programs evaluated in these studies consisted of
Internet. These successful online programs included a struc-               multiple components, but the programs were evaluated in
tured approach to modifying energy balance and the use of                  their entirety. Teasing out which components or combina-
cognitive-behavioural strategies such as self-monitoring.                  tions of components led to the study outcomes is difficult.
These findings were consistent with evidence from studies                   One exception is found in the study by Tate et al. (32),
of traditional weight loss programs, which points to using                 which allowed the researchers to specifically identify the
a combination of a low-calorie diet, increased physical                    importance of an e-counselling component that provided
activity, and behavioural or cognitive-behavioural therapy                 feedback, support, reinforcement and recommendations
for the most successful approach to weight loss and weight                 for change.
maintenance (33,34).                                                          Examining the control conditions used in the studies is
   The effective online programs also showed that per-                     also informative. Five of the studies (13,24,25,31,32) com-
sonalization through ongoing tailored information and                      pared research-based interventions that provided both
feedback, either via email from a human counsellor or                      structure and interactivity to the use of more information-
a computer-based program, was a critical component                         based, unstructured websites such as what is more typically
(13,24,25,31,32). Control groups consisting of Internet-                   found on the Internet. These studies allow us to conclude
based programs primarily delivering information and offer-                 that the positive effects found in the studies are not the
ing general online support were not effective in helping                   result of just having Internet access, but rather to the nature
participants lose weight.                                                  of the interventions themselves. Further, Womble et al.’s
   Three studies examined sites that were readily available                study (7) comparing eDiets.com to a weight loss manual
to the general public. The two studies (7,24) examining                    found that those using the manual lost more weight. This
eDiets failed to find substantial benefits from this program.                showed Internet-based programs lacking critical compo-
Although the eDiets program included information about                     nents, such as a structured approach, might not lead to the
diet and physical activity, opportunities for social support,              best weight loss.
and recommendations to record food intake, the research-                      Another consideration is how Internet-based programs
ers (7) concluded that it lacked the structured approach of                compare with other kinds of weight loss interventions. Tate
the manual used by the control group. Further, when eDiets                 et al. (31) found that their programme achieved weight loss


                                                                                                                                     © 2007 The Authors
                                           Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465
obesity reviews                                                                                 Internet for weight loss      S. L. Saperstein et al.      463




Table 1 Studies meeting inclusion criteria

Authors                  Study groups                                                              Results


Gold (24)                Intervention group: Access to vTrim that included diet and                Significant difference† intervention vs. control:
                            exercise information, social support in a facilitated small group      Weight loss: 18.3 lb. vs. 9 lb. with V-Trim participants also
                            experience, prescribed exercise plans with ongoing                       logging in more frequently, showing more changes in
                            feedback, online diet logs with feedback from a therapist and            eating behaviours and perceived social support than
                            structured lessons with homework                                         the eDiet participants.
                         Control group: Access to eDiets which offers diet and exercise
                            information and social support
Rothert et al. (13)      Intervention group: Self-help weight management program                   Significant difference intervention vs. control:
                            focusing on healthy diet, physical activity and cognitive-             At 3 months, weight loss: 2.6 ± 0.3 kg vs. 1.2 ± 0.3.**
                            behavioural strategies. Participants received tailored action          At 6 months, weight loss: 2.8 ± 0.3 kg vs. 1.1 ± 0.4.**
                            plans based on assessment data delivered at 3 points in the
                            program
                         Control group: Internet-based information-only website
Tate et al. (31)         Intervention group: Email messages and feedback from a                    Significant difference intervention vs. control group: Mean
                            therapist, an electronic bulletin board for peer support,                weight loss: 4.1 ± 4.5 vs. 1.6 ± 3.3 kg.**
                            requirement to report self-monitoring weekly and all control           Waist circumference loss: 6.4 ± 5.5 vs. 3.1 ± 4.4 cm.**
                            group resources                                                        Twice as many in the behaviour therapy group achieved
                         Control Group: Internet education about diet, exercise and                  a 5% weight loss goal.*
                            self-monitoring                                                        Higher login frequency in intervention group.**
Tate et al. (32)         Intervention group: Email communication with a weight loss                Significant difference intervention vs. control group:
                            counsellor, instruction to submit daily food diaries along with        Mean weight loss: 4.4 ± 6.2 vs. 2.0 ± 5.7 kg.*
                            all control group resources                                            Waist circumference loss: 7.2 ± 7.5 vs-4.4 ± 5.7 cm.*
                         Control group: Online weight loss tutorial, a weekly weight loss          Higher login frequency in intervention group.*
                            tip and a new link, a directory of selected Internet weight loss
                            resources, and a message board
Tate et al. (25)         Intervention group 1: Access to a free interactive website                At 3 months, weight losses were greater in the human
                            (Slimfast.com), a study website that contained an electronic             counselling group (−6.1 ± 3.9 kg) and the computer-
                            diary and message board, meal replacements, and human                    tailored group (−5.3 ± 4.2 kg) than the control group
                            email counselling                                                        (−2.8 ± 3.5 kg)** and intervention groups were not
                         Intervention group 2: Access to a free interactive website                  significantly different from each other.
                            (Slimfast.com), a study website that contained an electronic           At 6 months, weight losses were greater with the human
                            diary and message board, meal replacements and automated                 counselling (−7.3 ± 6.2 kg) than in the computer-tailored
                            tailored email: counselling                                              group (−4.9 ± 5.9 kg) or the control group
                         Control group: Access to a free interactive website                         (−2.6 ± 5.7 kg).**
                            (Slimfast.com) and meal replacements                                   Higher login frequency in intervention groups.**
                                                                                                   Greater use of public site correlated with greater weight
                                                                                                     loss in control group.*
                                                                                                   Diary submission associated with weight loss in
                                                                                                     intervention groups.**
Womble et al. (7)        Intervention group: Access to eDiets.com which offers diet and            Significant difference control vs. intervention group:
                            exercise information and social support                                Percentage weight loss: at week 16: manual users lost
                         Control group: Structured weight loss manual                                more than eDiets users: −3.6 ± 4.0% vs. 0.9 ± 3.2%.**
                                                                                                   At week 52: manual users lost more than eDiet users:
                                                                                                     4.0 ± 5.1% vs. 1.1 ± 4.0%.*
                                                                                                   Quality of life measures, blood pressure, glucose and lipid
                                                                                                     levels: no difference.


*P ≤ 0.05; **P ≤ 0.01.
†
 Level of significance not reported.




similar to other minimal interventions, such as mail corre-                        many more people lose some weight. Tate et al. (25)
spondence programs, but it did not perform as well as some                         showed the potential for programs using computer-auto-
in-person interventions. However, no study to date has                             mated feedback to produce similar weight loss as programs
compared the differential costs and public health benefits                          using e-counsellors, suggesting that the potential exists to
of face-to-face programs that might help fewer people lose                         develop fully automated systems that can reach large num-
more weight to Internet-based programs that could help                             bers of people at a greatly reduced cost.


© 2007 The Authors
Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465
464   Internet for weight loss   S. L. Saperstein et al.                                                                obesity reviews


   The findings from these studies showed that Internet-                    studies showed that those who logged in more frequently
based tools could help users lose weight if they provided a                also lost more weight. Therefore, patients need to know
structured, personalized program with an emphasis on diet,                 that programs can only be effective if people actively
physical activity and cognitive-behavioural strategies. Sites              participate in them.
using an unstructured approach or an information-only                         Several randomized controlled trials have shown great
approach without personalized feedback did not lead to                     potential for the Internet to deliver effective weight loss
significant weight loss. Unfortunately, successful research-                programs. Online programs that helped participants lose
driven tools are often not widely distributed or easily                    weight emphasized dietary and physical activity changes,
accessed by the general public (10).                                       used cognitive and behaviour strategies and provided per-
                                                                           sonalized feedback and support. However, readily available
                                                                           programs do not seem to provide the structure, behavioural
Discussion
                                                                           strategies, and personalized support that many people
This review examined three factors that can be used to                     seemed to need. Along with continued development and
determine the impact of online weight loss programs: the                   refinement of online programs, we need to determine meth-
general public’s interest in online weight loss, the types of              ods for increasing the distribution of programs with known
online weight loss programs available to the general public                efficacy.
and the known efficacy of online weight loss programs.                         In conclusion, the Internet appears to have great poten-
   The general public is turning to the Internet for diet,                 tial as a medium through which to deliver online weight
physical activity and weight loss information in increasing                loss programs. The reality is tempered by the actuality of
numbers. Two of the most popular health websites are                       limited distribution of effective theory-based programs
sites whose primary purpose is to help participants lose                   and the preponderance of readily available websites with
weight. However, we do not know much about people’s                        unknown effectiveness. The general public has shown
specific experience with online weight loss. Who is more                    increasing interest in online health information and weight
likely to use online weight loss websites? Do they use one                 loss assistance, but little research exists on the public’s
site or many sites? Do they make judgements about site                     readiness to use online weight loss programs and their
credibility? Do they pick and choose specific tools (such as                actual online experiences with such programs. Continued
body mass index calculators, online food diaries) from a                   efforts need to be made towards understanding who may
variety of sites? Are they deterred by costs associated with               be best served with online weight loss programs, gauging
some sites? Do they use the web as an adjunct to other in-                 the applicability of programs for more diverse audiences,
person weight loss programs? Do they stop using sites                      increasing the distribution of programs with known effi-
because their weight loss goals were met or because they                   cacy, and improving the public’s media literacy with respect
could not find adequate online programs? Are they able to                   to evaluating online weight loss programs.
find culturally appropriate programs? Research address-
ing these questions could help us further understand
                                                                           Conflict of Interest Statement
the potential reach and impact of online weight loss
programs.                                                                  No conflict of interest was declared.
   Studies of behaviour change websites, including those
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                                                                                                                                     © 2007 The Authors
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obesity reviews                                                                                Internet for weight loss   S. L. Saperstein et al.   465




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© 2007 The Authors
Journal compilation © 2007 The International Association for the Study of Obesity. obesity reviews 8, 459–465

								
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