The Change in Eating Behaviors in a Web-Based Weight Loss Program: A Longitudinal Analysis of Study Completers

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Figure 4. Change over time in uncontrolled eating behavior a) among women (n=524) and b) among men (n=96). Change over time in cognitive restraint eating behavior c) among women (n=524) and d) among men (n=96). Change over time in emotional eating behavior e) among women (n=524) and f) among men (n=96).

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Discussion

In this Web-based weight loss program, eating behavior changed during the 6-month program participation. We found that male participants changed all eating behaviors; cognitive restrained eating scores increased over 6 months, whereas uncontrolled and emotional eating scores decreased. Among our female participants, cognitive restrained eating increased and uncontrolled eating decreased during the program.

The effect of sex with respect to emotional eating is controversial in existing research. In our cohort, there was no significant difference between male and female participants’ emotional eating scores at baseline. We cannot exclude that an underlying selection process leading people to join the program may have affected baseline values, making them partially different from other cohorts in which different enrollment criteria were used. Interestingly, Ozier et al [40] found that men reporting high levels of emotional eating were almost 3 times as likely as women to be overweight. Because our participants were overweight at baseline, we were not able to make this comparison with respect to BMI and sex. However, Konttinen et al [41] reported greater tendencies among women to report higher emotional eating scores than men, a result also supported by Karlsson et al [26] in the Swedish Obese Subjects (SOS) study. In their study, half of all participants (n=4377) scored at the top of the TFEQ emotional eating scale. Almost 40% of male participants and 60% of female participants reported high emotional eating [26]. Hence, prior literature is in disagreement regarding the effect of sex on emotional eating.

Interestingly, Péneau et al [42] reported that former or current dieters had higher scores of emotional eating compared to those who had never dieted. A possible explanation for this change is the tendency to restrict food intake during specific time periods with a high number of relapses, which may contribute to increased risk for overeating caused by emotional cues [42,43]. Presumably, the participants who took part in our Web-based weight loss intervention have had a similar history of dieting as those described previously. It is likely that our participants, before signing up to the Weight Club, characterized the behaviors of a dieter, which in turn may have contributed to the amplified emotional eating score at baseline. Our male participants scored 57.2 and our female participants scored 45.1 on the 100-point TFEQ scale. These scores are in-line with the scores of an obese Swedish sample (BMI 44.5 kg/m2) scoring eating behavior before gastric bypass with TFEQ [44]. Interestingly, in a community-based French cohort with leaner subjects who might have a different history of dieting (the average BMI among the male participant was 26 kg/m2 and 25 kg/m2 among the female participants) the scores for emotional eating were much lower in men (TFEQ score=22), whereas women scored only slightly lower (TFEQ score=43) [37]. This may suggest that the background history of dieting should be considered in future weight loss interventions, particularly in men because it might affect the overall eating behavior and require personalized treatment methods to optimize weight loss.

Furthermore, the correlation between increased cognitive restrained eating behavior and weight loss for females that we found was put forward by Stunkard and Messick 30 years ago [18]. Other researchers proposed lowered BMI as a result of cognitive restrained eating behaviors [1921]. Cognitive restrained eating has, for example, been reported to be associated not only with low energy intake in a randomized weight loss intervention study [45], but also with long-term weight loss [46]. An increased cognitive restrained eating behavior may generate an overall improved self-control over food intake [47,48]. However, it should be emphasized that our results on eating behaviors do not imply causality, although it is conceivable that behaviors related to cognitive restrained, uncontrolled, and emotional eating may have an impact on food intake and ultimately weight loss.

The present study comprised a baseline sample of 22,844 participants submitting data on baseline characteristics and TFEQ-R18. To our knowledge, this is the largest Web-based research study conducted on eating behaviors to date, even if our study demonstrates a high prevalence of participant attrition. Neve et al [49] reported that commercial Web-based weight loss programs generally show high attrition rates. The authors propose a relationship between higher nonusage attrition and age, exercise level, emotional eating habits, eating breakfast, and skipping meals. A careful drop-out analysis investigating when the participants left the study with respect to basic characteristics, health aspects, and TFEQ-scores would have strengthened our study. However, such an analysis is difficult to conduct in a commercial Web-based weight loss program due to our inability to control compliance.

The absence of a control group prevents us from concluding that the observed changes in eating behaviors actually occurred as a result of participating in our Web-based weight loss program. Besides, we did not see a statistical relationship between the frequency of log-ins and greater change in eating behavior. We cannot exclude the possibility that any dieting person would experience similar changes over a 6-month period. Or indeed, that the simple act of repeatedly answering questions about eating behavior may cause one to adjust one’s eating behavior or cause an increased awareness of one’s eating behavior, which would affect subsequent self-reports [50]. For example, recent evidence suggests that self-reports of emotional eating reflect concern over emotional eating, rather than the actual act of eating when feeling emotional [22,51].

Our final analyses included a total of 620 participants, of which 96 were men. It is not surprising that more than 80% of our baseline participants were women; rather, this is a common phenomenon in health research [52]. Additionally, the completers in our study were older than the noncompleters, supporting previous research on age groups engaged in Web-based weight loss programs, in which older participants have shown higher compliance rates than younger ones [15,53,54].

According to recent statistics, Swedish citizens older than age 45 years are less likely to use the Internet on a daily basis compared to younger citizens, primarily due to lack of interest [55]. However, according to a report on Internet statistics, almost 90% of the Swedish population had access to the Internet in 2012 [55] suggesting high computer literacy in the Swedish population. Yet Web-based health interventions require certain levels of health technology literacy among the participants—the skills to read, understand, and personalize health information communicated via the Web and to be able to transform this information into action [56]. A selection of participants with high level of health technology literacy is thus possible in the present study. Therefore, older individuals who have access to the Internet may be an important target group in Web-based interventions because they seem more receptive to this type of intervention.

Although this study admits its limitations, our results add further understanding of baseline eating behaviors among overweight individuals and how eating behaviors changed during 6 months participating in a Web-based weight loss program. Enhanced knowledge about eating behaviors among individuals taking part in weight loss intervention programs might open opportunities for health professionals to personalize treatment and overall health care, meeting the needs and preferences of the target group.

This Web-based weight loss intervention suggests that eating behaviors (cognitive restrained eating, uncontrolled eating, and emotional eating) measured by TFEQ-R18 were significantly changed during 6 months of participation. Cognitive restrained eating scores increased and uncontrolled eating scores decreased among both male and female participants, whereas emotional eating scores only decreased among male participants. Our findings indicate differences in eating behaviors with respect to sex, but should be interpreted with caution because attrition was high.

Acknowledgments

The authors would like to convey a special thank you Professor Albert J Stunkard for his valuable feedback and inspiring discussions during the initial writing phase of the manuscript. We would also like to extend a special thank you to Elisabet Frigell, research librarian at Halmstad University, for her valuable assistance and participation in literature searches during the revision process of the manuscript.

Conflicts of Interest

Josefine Jonasson is employed part time by Aftonbladet, the Swedish newspaper the authors collaborated with to develop the weight loss program studied in this project. She was one of the dietitians in charge of the weight loss program. Stephan Rössner received consulting fees from Aftonbladet during the early development and design of the weight loss program.

References

  1. World Health Organization. Data and statistics: The challenge of obesity-quick statistics
      URL: http://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity/data-and-statistics [accessed 2014-09-23]
    [WebCite Cache]
  2. World Health Organization. preventing and managing the global epidemic Report of a WHO Consultation (WHO Technical Report Series 894). Geneva: WHO; 2014.
  3. Neve MJ, Morgan PJ, Collins CE. Participant characteristics and reach of a commercial web-based weight loss program. Nutr Diet 2010;67(4):267-274. [CrossRef]
  4. Wieland LS, Falzon L, Sciamanna CN, Trudeau KJ, Brodney S, Schwartz JE. Interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people. The Cochrane database of systematic reviews 2012;8. [CrossRef] [Medline]
  5. Rasu RS, Hunter CM, Peterson AL, Maruska HM, Foreyt JP. Economic evaluation of an Internet-based weight management program. Am J Manag Care 2010 Apr;16(4):e98-104 [FREE Full text] [Medline]
  6. Krukowski RA, Tilford JM, Harvey-Berino J, West DS. Comparing behavioral weight loss modalities: incremental cost-effectiveness of an internet-based versus an in-person condition. Obesity (Silver Spring) 2011 Aug;19(8):1629-1635 [FREE Full text] [CrossRef] [Medline]
  7. Postrach E, Aspalter R, Elbelt U, Koller M, Longin R, Schulzke JD, et al. Determinants of successful weight loss after using a commercial web-based weight reduction program for six months: cohort study. J Med Internet Res 2013;15(10):e219 [FREE Full text] [CrossRef] [Medline]
  8. Svensson M, Lagerros YT. Motivational technologies to promote weight loss–from internet to gadgets. Patient Educ Couns 2010 Jun;79(3):356-360. [CrossRef] [Medline]
  9. Tang J, Abraham C, Greaves C, Yates T. Self-directed interventions to promote weight loss: a systematic review of reviews. J Med Internet Res 2014;16(2):e58 [FREE Full text] [CrossRef] [Medline]
  10. Viktklubb. Viktklubb Hem. 2014.
      URL: http://viktklubb.aftonbladet.se/v4/hem/hem [accessed 2014-09-23]
    [WebCite Cache]
  11. van der Mark M, Jonasson J, Svensson M, Linné Y, Rossner S, Lagerros YT. Older members perform better in an internet-based behavioral weight loss program compared to younger members. Obes Facts 2009;2(2):74-79. [CrossRef] [Medline]
  12. Neve M, Morgan PJ, Jones PR, Collins CE. Effectiveness of web-based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: a systematic review with meta-analysis. Obes Rev 2010 Apr;11(4):306-321. [CrossRef] [Medline]
  13. Liebermeister H. Effects of weight-reduction on obesity-associated diseases. German medical science : GMS e-journal 2003;1:1-3. [Medline]
  14. Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992 Jun;16(6):397-415. [Medline]
  15. Brindal E, Freyne J, Saunders I, Berkovsky S, Smith G, Noakes M. Features predicting weight loss in overweight or obese participants in a web-based intervention: randomized trial. J Med Internet Res 2012;14(6):e173 [FREE Full text] [CrossRef] [Medline]
  16. Neve MJ, Morgan PJ, Collins CE. Behavioural factors related with successful weight loss 15 months post-enrolment in a commercial web-based weight-loss programme. Public Health Nutr 2012 Jul;15(7):1299-1309. [CrossRef] [Medline]
  17. Egger GJ, Binns AF, Rossner SR. The emergence of “lifestyle medicine” as a structured approach for management of chronic disease. Med J Aust 2009 Feb 2;190(3):143-145. [Medline]
  18. Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res 1985;29(1):71-83. [Medline]
  19. Papies EK, Stroebe W, Aarts H. Who likes it more? Restrained eaters’ implicit attitudes towards food. Appetite 2009 Dec;53(3):279-287. [CrossRef] [Medline]
  20. Savage JS, Hoffman L, Birch LL. Dieting, restraint, and disinhibition predict women’s weight change over 6 y. Am J Clin Nutr 2009 Jul;90(1):33-40 [FREE Full text] [CrossRef] [Medline]
  21. Rideout CA, Barr SI. “Restrained eating” vs “trying to lose weight”: how are they associated with body weight and tendency to overeat among postmenopausal women? J Am Diet Assoc 2009 May;109(5):890-893. [CrossRef] [Medline]
  22. Lluch A, Herbeth B, Méjean L, Siest G. Dietary intakes, eating style and overweight in the Stanislas Family Study. Int J Obes Relat Metab Disord 2000 Nov;24(11):1493-1499. [Medline]
  23. Lowe MR, Doshi SD, Katterman SN, Feig EH. Dieting and restrained eating as prospective predictors of weight gain. Front Psychol 2013;4:577 [FREE Full text] [CrossRef] [Medline]
  24. Dykes J, Brunner EJ, Martikainen PT, Wardle J. Socioeconomic gradient in body size and obesity among women: the role of dietary restraint, disinhibition and hunger in the Whitehall II study. Int J Obes Relat Metab Disord 2004 Feb;28(2):262-268. [CrossRef] [Medline]
  25. Tholin S, Rasmussen F, Tynelius P, Karlsson J. Genetic and environmental influences on eating behavior: the Swedish Young Male Twins Study. Am J Clin Nutr 2005 Mar;81(3):564-569 [FREE Full text] [Medline]
  26. Karlsson J, Persson LO, Sjöström L, Sullivan M. Psychometric properties and factor structure of the Three-Factor Eating Questionnaire (TFEQ) in obese men and women. Results from the Swedish Obese Subjects (SOS) study. Int J Obes Relat Metab Disord 2000 Dec;24(12):1715-1725. [Medline]
  27. Yeomans MR, Leitch M, Mobini S. Impulsivity is associated with the disinhibition but not restraint factor from the Three Factor Eating Questionnaire. Appetite 2008;50(2-3):469-476. [CrossRef] [Medline]
  28. Lindroos AK, Lissner L, Mathiassen ME, Karlsson J, Sullivan M, Bengtsson C, et al. Dietary intake in relation to restrained eating, disinhibition, and hunger in obese and nonobese Swedish women. Obes Res 1997 May;5(3):175-182. [Medline]
  29. Masheb RM, Grilo CM. On the relation of flexible and rigid control of eating to body mass index and overeating in patients with binge eating disorder. Int J Eat Disord 2002 Jan;31(1):82-91. [Medline]
  30. Angle S, Engblom J, Eriksson T, Kautiainen S, Saha MT, Lindfors P. Three factor eating questionnaire-R18 as a measure of cognitive restraint, uncontrolled eating and emotional eating in a sample of young Finnish females. Int J Behav Nutr Phys Act 2009;6:1-6. [CrossRef]
  31. Nguyen-Rodriguez ST, Chou CP, Unger JB, Spruijt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008 Apr;9(2):238-246 [FREE Full text] [CrossRef] [Medline]
  32. Koenders PG, van Strien T. Emotional eating, rather than lifestyle behavior, drives weight gain in a prospective study in 1562 employees. J Occup Environ Med 2011 Nov;53(11):1287-1293. [CrossRef] [Medline]
  33. Aftonbladet Hierta AB. Aftonbladet.
      URL: http://www.aftonbladet.se/ [accessed 2014-09-23]
    [WebCite Cache]
  34. Harris JA, Benedict FG. A Biometric Study of Human Basal Metabolism. Proc Natl Acad Sci U S A 1918 Dec;4(12):370-373 [FREE Full text] [Medline]
  35. Provencher V, Drapeau V, Tremblay A, Després JP, Lemieux S. Eating behaviors and indexes of body composition in men and women from the Québec family study. Obes Res 2003 Jun;11(6):783-792. [CrossRef] [Medline]
  36. de Lauzon-Guillain B, Basdevant A, Romon M, Karlsson J, Borys JM, Charles MA, FLVS Study Group. Is restrained eating a risk factor for weight gain in a general population? Am J Clin Nutr 2006 Jan;83(1):132-138 [FREE Full text] [Medline]
  37. de Lauzon B, Romon M, Deschamps V, Lafay L, Borys JM, Karlsson J, Fleurbaix Laventie Ville Sante Study Group. The Three-Factor Eating Questionnaire-R18 is able to distinguish among different eating patterns in a general population. J Nutr 2004 Sep;134(9):2372-2380 [FREE Full text] [Medline]
  38. Lähteenmäki L, Tuorila H. Three-factor eating questionnaire and the use and liking of sweet and fat among dieters. Physiol Behav 1995 Jan;57(1):81-88. [Medline]
  39. Bond MJ, McDowell AJ, Wilkinson JY. The measurement of dietary restraint, disinhibition and hunger: an examination of the factor structure of the Three Factor Eating Questionnaire (TFEQ). Int J Obes Relat Metab Disord 2001 Jun;25(6):900-906. [CrossRef] [Medline]
  40. Ozier AD, Kendrick OW, Leeper JD, Knol LL, Perko M, Burnham J. Overweight and obesity are associated with emotion- and stress-related eating as measured by the eating and appraisal due to emotions and stress questionnaire. J Am Diet Assoc 2008 Jan;108(1):49-56. [CrossRef] [Medline]
  41. Konttinen H, Männistö S, Sarlio-Lähteenkorva S, Silventoinen K, Haukkala A. Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite 2010 Jun;54(3):473-479. [CrossRef] [Medline]
  42. Péneau S, Ménard E, Méjean C, Bellisle F, Hercberg S. Sex and dieting modify the association between emotional eating and weight status. Am J Clin Nutr 2013 Jun;97(6):1307-1313 [FREE Full text] [CrossRef] [Medline]
  43. Cools J, Schotte DE, McNally RJ. Emotional arousal and overeating in restrained eaters. J Abnorm Psychol 1992 May;101(2):348-351. [Medline]
  44. Laurenius A, Larsson I, Bueter M, Melanson KJ, Bosaeus I, Forslund HB, et al. Changes in eating behaviour and meal pattern following Roux-en-Y gastric bypass. Int J Obes (Lond) 2012 Mar;36(3):348-355. [CrossRef] [Medline]
  45. Keränen AM, Strengell K, Savolainen MJ, Laitinen JH. Effect of weight loss intervention on the association between eating behaviour measured by TFEQ-18 and dietary intake in adults. Appetite 2011 Feb;56(1):156-162. [CrossRef] [Medline]
  46. Keränen AM, Savolainen MJ, Reponen AH, Kujari ML, Lindeman SM, Bloigu RS, et al. The effect of eating behavior on weight loss and maintenance during a lifestyle intervention. Prev Med 2009 Aug;49(1):32-38. [CrossRef] [Medline]
  47. Bellisle F, Clément K, Le Barzic M, Le Gall A, Guy-Grand B, Basdevant A. The Eating Inventory and body adiposity from leanness to massive obesity: a study of 2509 adults. Obes Res 2004 Dec;12(12):2023-2030. [CrossRef] [Medline]
  48. Elfhag K, Morey LC. Personality traits and eating behavior in the obese: poor self-control in emotional and external eating but personality assets in restrained eating. Eat Behav 2008 Aug;9(3):285-293. [CrossRef] [Medline]
  49. Neve MJ, Collins CE, Morgan PJ. Dropout, nonusage attrition, and pretreatment predictors of nonusage attrition in a commercial Web-based weight loss program. J Med Internet Res 2010;12(4):e69 [FREE Full text] [CrossRef] [Medline]
  50. Dholakia UA, Gopinath M, Bagozzi RP, Nataraajan R. The role of regulatory focus in the experience and self-control of desire for temptations. J Consum Psychol 2006;16(2):163-175. [CrossRef]
  51. Evers C, de Ridder DT, Adriaanse MA. Assessing yourself as an emotional eater: mission impossible? Health Psychol 2009 Nov;28(6):717-725. [CrossRef] [Medline]
  52. Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol 2007 Sep;17(9):643-653. [CrossRef] [Medline]
  53. Funk KL, Stevens VJ, Appel LJ, Bauck A, Brantley PJ, Champagne CM, et al. Associations of internet website use with weight change in a long-term weight loss maintenance program. J Med Internet Res 2010;12(3):e29 [FREE Full text] [CrossRef] [Medline]
  54. Kelders SM, Van Gemert-Pijnen JE, Werkman A, Nijland N, Seydel ER. Effectiveness of a Web-based intervention aimed at healthy dietary and physical activity behavior: a randomized controlled trial about users and usage. J Med Internet Res 2011;13(2):e32 [FREE Full text] [CrossRef] [Medline]
  55. Findahl O. Swedes and the Internet 2013. Stockholm: .SE (the Internet Infrastructure Foundation); 2011.
      URL: https://www.iis.se/docs/Swedes_and_the_internet-2013.pdf [accessed 2014-09-23]
    [WebCite Cache]
  56. HealthyPeople.gov. Washington, DC: US Department of Health and Human Services Health Communication and Health Information Technology
      URL: http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=18 [accessed 2014-09-23]
    [
    WebCite Cache]



Abbreviations


Edited by G Eysenbach; submitted 02.12.13; peer-reviewed by K Tapper, M Hutchesson, S Wieland; comments to author 12.02.14; revised version received 07.04.14; accepted 22.07.14; published 03.11.14

©Madeleine Svensson, Mari Hult, Marianne van der Mark, Alessandra Grotta, Josefine Jonasson, Yvonne von Hausswolff-Juhlin, Stephan Rössner, Ylva Trolle Lagerros. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 3.11.2014.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.


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