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  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 [ ] reported greater tendencies among women to report higher emotional eating scores than men, a result also supported by Karlsson et al [ ] 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 [ ]. Hence, prior literature is in disagreement regarding the effect of sex on emotional eating.
Interestingly, Péneau et al  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 [ , ]. 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 [ ]. 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) [ ]. 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 . Other researchers proposed lowered BMI as a result of cognitive restrained eating behaviors [ – ]. Cognitive restrained eating has, for example, been reported to be associated not only with low energy intake in a randomized weight loss intervention study [ ], but also with long-term weight loss [ ]. An increased cognitive restrained eating behavior may generate an overall improved self-control over food intake [ , ]. 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  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 . 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 [ , ].
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 . 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 [ , , ].
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 . However, according to a report on Internet statistics, almost 90% of the Swedish population had access to the Internet in 2012 [ ] 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 [ ]. 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.
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.
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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.
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