Sustained Weight Loss during 20 Months using a Personalized Interactive Internet Based Dietician Advice Program in a General Practice Setting

Abstract

Obesity is an increasing drain on the resources of general practitioners, who have few effective options for treatment other than surgery and (often prohibitively expensive) personal dietician advice. This pilot project investigated the weight loss efficacy and the cost of an interactive internet-based weight loss program in a Danish medical center setting. The study comprised an initial weight loss period of approximately 4 months, consisting of frequent online consultations with a dietician and an exercise coach supported by electronic diaries and establishment of an online community, where the patients exchanged experiences with other users of the program. This was followed by a 16-month maintenance treatment providing less intensive counseling. Of 46 obese patients offered participation, 32 patients were enrolled in the study and 21 completed the full course. The mean weight at inclusion was 104 kg with a BMI of 36.4 kg/m 2 . After 4 months of treatment and an average of 17 consultations the participants lost on average 7.0 kg, p<0.001. During the 16-month maintenance period, the average weight did not change and 81% of the participants retained or increased their initial weight loss. The cost of the initial treatment was calculated as 165 DKK (approx. €22) per kg weight lost. These results indicate that e-mail consultations can produce comparable weight loss as conventional weight loss treatments in general practice at a lower cost, particularly for sustaining the weight loss over a longer period of time. The results of this preliminary uncontrolled study with few participants indicate that future randomized clinical trials with more participants comparing the e-consultations with relevant conventional practices are justified, in order to quantify effect and long-term cost-efficiency of e-consultations as an intervention against obesity.

Full text

Sustained Weight Loss during 20 Months using a Personalized Interactive Internet
Based Dietician Advice Program in a General Practice Setting
Vibeke Brandt
University of Southern Denmark
Odense, Denmark
e-mail: vibra@student.sdu.dk
Carl J. Brandt
Stenstrup Lægehus
Svendborg, Denmark
e-mail: carl_brandt@get2net.dk
Dorte Glintborg
Department of Endocrinology M
Odense University Hospital
Odense, Denmark
e-mail: dorte.glintborg@dadlnet.dk
Cecilia Arendal
Clinical Dietician
Nyborg, Denmark
e-mail: cia-erik@adslhome.dk
Søren Toubro
Reduce
Roskilde, Denmark
e-mail: st@reduce.dk
Kirsten Brandt
Human Nutrition Research Centre, School of Agriculture,
Food and Rural Development
Newcastle University
Newcastle upon Tyne, United Kingdom
e-mail: kirsten.brandt@newcastle.ac.uk
Abstract—Obesity is an increasing drain on the resources
of general practitioners, who have few effective options for
treatment other than surgery and (often prohibitively
expensive) personal dietician advice. This pilot project
investigated the weight loss efficacy and the cost of an
interactive internet-based weight loss program in a Danish
medical center setting. The study comprised an initial weight
loss period of approximately 4 months, consisting of frequent
online consultations with a dietician and an exercise coach
supported by electronic diaries and establishment of an online
community, where the patients exchanged experiences with
other users of the program. This was followed by a 16-month
maintenance treatment providing less intensive counseling. Of
46 obese patients offered participation, 32 patients were
enrolled in the study and 21 completed the full course. The
mean weight at inclusion was 104 kg with a BMI of 36.4 kg/m
2
.
After 4 months of treatment and an average of 17 consultations
the participants lost on average 7.0 kg, p<0.001. During the 16-
month maintenance period, the average weight did not change
and 81% of the participants retained or increased their initial
weight loss. The cost of the initial treatment was calculated as
165 DKK (approx. €22) per kg weight lost. These results
indicate that e-mail consultations can produce comparable
weight loss as conventional weight loss treatments in general
practice at a lower cost, particularly for sustaining the weight
loss over a longer period of time. The results of this
preliminary uncontrolled study with few participants indicate
that future randomized clinical trials with more participants
comparing the e-consultations with relevant conventional
practices are justified, in order to quantify effect and long-
term cost-efficiency of e-consultations as an intervention
against obesity.
Keywords-obesity; internet community; treatment; preventive
medicine
I. INTRODUCTION
Obesity is a growing problem, resulting in an increasing
demand for efficient weight loss treatments suitable for use
in general practice settings [1]. According to the
Framingham study, obesity shortens life by 3 to 8 years for a
40-year-old person [2] demonstrating the urgent need for
effective ways to reduce obesity.
Form and content of communication are important in
order to modify life style factors [3], which is the general
recommendation to obtain a sustainable weight reduction.
Several Cochrane reviews infer that advice from general
practitioners (GPs) by itself does not have a long-term effect
on weight loss compared to placebo [4]. Dietician guidance
and the establishment of group meetings have a significant
effect in the short term, but only few long-term studies are
available [4][5]. Surgical intervention is an effective long-
term weight loss option, but in Denmark it is reserved for
very obese patients [5]. Consequently no documented
effective non-surgical weight loss offers are available to the
GPs of the Danish National Health Service for patients with
simple overweight [6].
There is now a vast literature on how the internet can be
integrated as a consultation tool [5][7][8][9]. For example,
several studies suggest that interaction over the internet with
experts in an internet based community is the most effective
way to lose weight [10][11]. Recent studies suggest that
online contacts are an economically attractive contact form
for optimizing guidance on diet and exercise and in keeping
the patients motivated [12][13][14]. The internet furthermore
substantially facilitates the use of motivational tools such as
self-monitoring, which has been used successfully in other
approaches of internet based weight loss interventions [16].
23
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org

In Denmark, 86 % of the population has internet access at
home [15], which makes it possible to reach out to most of
the patients by online intervention.
Conventional dietician advice is costly, therefore it is
important to ensure that resources are being used in the best
way possible. In Denmark it is now possible to employ
dieticians in general practice and health care centers.
However many practices experience difficulties to organize
the activities in a way that makes it economically feasible to
offer diet treatment to patients within the rates provided by
the Danish National Health Service.
The present paper reports on the methods used and
results achieved in a preliminary uncontrolled prospective
survey of weight loss and weight maintenance among obese
patients, who received advice and support about diet and
exercise using a personalized interactive internet-based
dietician advice program in a clinical practice setting.
II. METHOD AND SUBJECTS
A. Patients
One medical center with primary care participated in the
study. In May 2008, new patients and patients who were
already enrolled in weight stabilization courses were offered
the opportunity to participate. Initially 46 patients attended a
consultation with a dietician, of which 32 patients agreed to
participate in the full study and signed the informed consent
form. Patients then received information on how they could
log on to the program. Before attending the dietician, the
patients filled out name, address and e-mail address. The
study was approved by the South Danish regional committee
on biomedical ethics.
Figure 1. Screenshot of dietary notations on a daily basis from one of the
participants using the website.
B. Study design
The pilot study was designed as an uncontrolled
prospective survey of the efficacy of using an existing
commercial weight loss program [17] for obese patients in a
general practice setting. At the first login, patients filled out a
comprehensive 16-page medical history with information
regarding their health, education and medicine intake.
Completing the forms gave e-access to consultations with a
dietician and an exercise coach.
E-access also allowed e-mail chats with the other patients
participating in the study.
During the first week the patients recorded a diet and
exercise history on a day-to-day basis (see Figure 1). Based
on these records, the patients received a diet plan, weekly
advice from a dietitian (see figure 2) as well as an exercise
plan and advice from an exercise coach once a month.
Treatment principles in both online and physical
consultations were based on the Danish Board of Health's
recommendations from "The 8 dietary guidelines" [6].
The aim was to enhance the daily intake of vegetables
and fruits, choose whole-grain options for bread and other
cereal products, replace products rich in fat with lean
alternatives and distribute food intake into several smaller
meals throughout the day.
The treatment consisted of providing simple and
manageable guidelines and tools that gave the patients
substantial freedom in planning their meals while the
dietitian could supervise and advise each patient individually
on where improvements could be achieved. Patients who
according to the dietician’s professional assessment needed
face-to-face consultation with the dietician during the study
period, were seen by a dietician in the medical center 2 to 3
months into the study period. Only one dietitian was
connected to the project, which means that the patients were
met by the same dietician at the medical center as online.
Figure 2. Screenshot of personal advice from the dietician as a response to
the information in Figure 1.
24
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org

The internet tools in the program encouraged the patients
to record their exact dietary intake on a day-to-day basis,
enabling the dieticians at the face-to-face consultation to
focus more on serving the patient’s needs and spend less
time to simply clarify recent food intake. The patients could
also write about any complication or worry that they might
have during a day, as illustrated in the example in Figure 1.
Dietary notes and commentaries from the patients were used
by the dietician, the exercise coach as well as peers (other
users of the program) to intervene and relate to problems
when they appeared.
The patients were supported by their peers on the website
by using an internet community (presented as ‘forums for
debate), consisting of all users of the internet based program,
both the patients enrolled in the study and other users who
pay for the service privately to lose weight in a non-clinical
setting. The members of this internet community were
encouraged to contact each other for support, as seen in the
example in Figure 3.
The internet community was very intimate as only
patients with a weight problem had access. The patients
could communicate via discussion forums and internet chat
forums. Communication was also available in specially
designed inboxes on the website, as comments to food and
exercise records or via personal pictures.
To illustrate this we have chosen some typical
comments from the patients: “I know I don’t use as many
fiber rich vegetables in my salad as I would like, but there is
no room when I eat my regular salad that I love…” “…the
weather makes it difficult for me to exercise because of my
gout. What can I do?” or “my dog died. I’m so sad…”. The
dietician would get to know every participant individually,
and be able to guide them in a way that suited their lifestyle,
as seen in Figure 2.
Figure 3. Screenshot of participants using the debate forums from the
internet community.
Waist and hip measurement, weight and clinical analysis
values were obtained at baseline and after 4 month initial
treatment. These assessments were performed by the study
team at physical consultations, see table 1. The following
approx. 16 months (maintenance period) most of the patients
continued to use the program, but only received internet
consultations when requested by the patient or by the
dietician, and weight measurements were recorded whenever
the patients attended the health centers for other reasons.
Results were analyzed as a one-sample t-test for the
hypothesis that the weight loss or other change from one
time point to the next was different from 0.
III. RESULTS
The datasets from 22 of the 32 enrolled patients were
sufficiently complete to be included in the outcome
calculations. Of the remaining 10 patients, 2 only registered
starting weight and the remaining 8 never logged on. All 22
completed the initial treatment period and 21 the
maintenance treatment. One patient only completed a 12-
month period due to pregnancy; we used the last observation
carried forward. Baseline data and details of treatment for the
22 patients who participated in the are given in Table 1.
The average weight loss after the initial intensive
treatment period of 115 days (95% CI: 101; 121),was 7.0 kg,
with a standard error of the mean of 1.1 (95% CI: 4.6, 9.3),
P<0.001. Nine participants achieved a weight loss of 5-10 kg
and 4 participants lost more than 10 kg. There were no
significant correlations between weight loss and duration of
treatment period or between weight loss and number of
consultations. Clinical and anthropomorphic data of patients
enrolled are listed in Table 1. The mean age at inclusion was
43 years and the mean weight 104 kg with a BMI of 36.4
kg/m
2
.
Figure 4. Average weight of the participants at baseline, after 4 months and
after 20 months follow up.
85#
90#
95#
100#
105#
110#
115#
'4# 0# 4# 8# 12# 16# 20# 24#
Weight'(Kg)'
Time'from'start'of'intervention'
(Months)'
Changes'in'average'weight'
Female#
Male#
25
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org

Data presented as mean value (95% confidence interval)
* p<0.05 vs. before related to same sex
** p<0.001 vs. before related to same sex
*** Two patients were excluded due to pregnancy and absence; we used last observation carried forward (one after 4 months and one after 10 months)
The mean weight loss from baseline after the
maintenance period, a total of approx. 20 months, 595 days
(95% CI: 519; 671), was still 7.0 kg. 15 out of 21 achieved a
weight loss between 5 and 29 kg. 4 lost between 0.3 and 2.2
kg, and the last 3 patients gained between 0.1 and 4.7 kg.
One patient became pregnant and 1 patient was absent for
the approx. 20 month assessment, they were excluded and
we used the last observation carried forward. Seventeen out
of the 21 i.e. 81% of the participants managed to sustain a
weight loss of more than 1 kg after 20 months.
The dietician and some of the patients were interviewed
about their experience with the program. Both parties agreed
that one of the most important parts of the program was the
continuity. The dietician was always available over the
internet, which created an ongoing motivation for lifestyle
changes instead of a short-term diet change. The patients also
found that continuous emotional support and practical advice
from peers had been very important during the study.
Some patients found the internet community equally
important as the dietician, as illustrated by a comment: “I
spend most of my time on the internet community, I like to
see how the others are doing and whether they have the same
problems as me.”
Feedback from the doctors and staff in the medical center
indicated that they were satisfied with the cooperation with
the dietician. It was seen as a benefit to offer dietician advice
close to the patients without requiring frequent visits to the
medical center. The main challenge mentioned by this group
was the technical integration with the existing e-journal
system of the Danish National Health Service.
The total cost of the initial weight loss treatment,
including the personal (face-to-face) consultations and
clinical assessments, was estimated to a total of
approximately 35,000DKK. Without the cost of the study
assessments the cost would have been approximately 25,700
DKK. This estimate corresponds to 165 DKK (€22) per kg
weight lost for the treatment provided.
TABLE 1. Clinical and anthropomorphic data for the patients. Full set of data at baseline and after the initial treatment period, only weight measurements
after the approx. 20 months maintenance period.
Females (n=17)
Males (n=5)
Age(years)
42 (39-46)
43 (37-50)
Start
4 months
20 months
Start
4 months
20 months
E-mail cons.
0
17 (14-20)
57 (45-70)
0
17 (12-21)
29(18-39)
Period
(days)
111 (97-126)
568 (485-650)
130 (119-140)
683 (649-717)
Weight (kg)
101
(94-108)
93
(85-100)**
94***
(85-102)**
113
(108-117)
111
(105 -116)*
107
(101-113)*
BMI
(kg/m
2
)
35.6
(32.9-38.2)
32.6
(29.9-35.3)**
32.9
(29.9-36.0)**
39.1
(38.0-40.2)
38.4
(37.1-39.8)
37.3
(33.0-41.6)
Waist (cm)
103.2
(97.3-109.2)
95.4
(90.2-100.)*
122.7
(119.9-125.5)
120.3
(116.6-124.1)
Hip (cm)
119
(112.1-125.8)
109.4
(104.2-114.6)*
113.5
(112.5-114.5)
113.5
(112.5-114.5)
WHR
0.86
(0.82-0.93)
0.86
(0.82-0.93)
1.10
(1.07-1.13)
1.09
(1.04-1.13)
Total
cholesterol
5.2
(4.6-5.7)
4.9
(4.4-5.3)
5.8
(5.6-6.0)
5.0
(4.5-5.5)
LDL
(mmol/l)
3.1
(2.5-3.6)
3.0
(2.5-3.4)
3.3
(3.0-3.5)
3.5
(3.3-3.7)
HDL
(mmol/l)
1.7
(1.1-1.4)
1.7
(1.1-1.4)
1.0
(0.8-1.1)
1.1
(1.0-1.1)
TG
(mmol/l)
1.7
(1.3-2.1)
1.3
(1.0-1.6)
4.2
(3.3-5.1)
2.2
(1.6-2.7)
HbA1c (%)
5.0
(5.3-6.8)
5.2
(5.2-6.3)
8.0
(6.6-8.7)
7.0
(6.0-7.8)
26
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org

The cost to the Danish National Health Service of an e-mail
consultation was 49.68DKK, compared with 211.14DKK for
a consultation in the medical center with the aim of assisting
the patient to change lifestyle. The average price per patient
for the 4-month weight loss process in this implementation
study was 1165 DKK. Data on costs are not available for the
subsequent maintenance period, but they were substantially
lower than during the initial treatment period.
IV. DISCUSSION
In the present study we used a combination of the expertise
available to a Danish health center with an interactive e-
consultation delivery tool and an internet community to
accomplish a sustainable weight loss amongst obese Danes.
Using this method we achieved an average weight loss of 7.0
kg during the first 4 months, which is comparable to other
conventional treatments [10]. A maintained average weight
loss of 7.0 kg after 20 months follow up is a strong indicator
that this might be a way to efficiently and cost-effectively
reduce weight for a large population. However a
randomized controlled trial would be necessary to determine
whether the results are reproducible.
Bennett et al recently reported on a randomized clinical
trial of another web-based weight loss program in primary
care in the USA, with a similar study population (baseline
BMI 34.6 and age 54.4). This study showed a comparable
efficacy with a 3.05 kg greater weight loss amongst cases
compared with usual care. The trial period was 12 weeks and
one of their conclusions was that trials of longer duration are
necessary [16].
This study however displayed several differences from
ours, i.e. they tried to create adherence to the program by
offering the possibility of winning money and their internet
program did not include facilitated peer support (online
community). Since many of the patients used the community
frequently during our study and found it very beneficial this
may be an important difference. Also the patients in our
study corresponded with the same dietician over the internet
and during the counseling in general practice, in contrast to
the study of Bennett et al [16], where the program was not
designed to provide individual counseling. Using the
patient’s interaction with the community and e-mails from
the patient, the dietician could follow the patients' progress
and provide more accurate and effective advice, since she
had the opportunity to build a greater understanding of every
individual. Together with the longer weight loss period this
might be a reason why our study appeared to show a larger
weight loss, while their results are more significant due to a
higher number of participants and more relevant due to the
comparison with a control group. However in combination
these two studies strongly indicate that as a concept internet
based weight loss programs can be successful in the short
term, may be useful in longer term maintenance of weigh
loss and can be effectively introduced in health care.
Several studies suggest that keeping the patients in the
program is as effective as frequent follow-up but cheaper [5].
In the present study, the low number of dropouts among
those who progressed beyond the first week was remarkable;
according to the patients this was mainly due to the
community, where they established relationships with other
patients. The low dropout rate could also be affected by the
fact that the patients all received advice from the same
dietician, and she could possibly be very good at keeping the
patients motivated. It would be interesting to further
investigate specifically the efficacy of the internet
community, since the Bennet et al. study showed that the
more patients were using the internet program, the greater
their weight loss [16], even though no such correlation was
found with the small number of participants in the present
study. Future developments of the program could focus on
the community and make it more attractive. We may achieve
greater and in particular more sustained weight loss results if
we could get the patients more involved in the program
through the internet community.
The use of self-monitoring provided by the online
program had both advantages and disadvantages. The
patients were able to follow their own progress using the
website, which can help keep motivation, and the data that
the patients provided were essential as tools for the dietitian
to achieve the very cost-effective provision of advice. In
contrast, the self-reported data could not be used for,
evaluation of the intervention outcome, due to potential bias
such as under- or over-estimations or recall bias. Therefore
only data from measurements that were carried out at the
medical center by the dietician or a nurse are presented in the
present paper.
Web-based interventions have the disadvantage that the
participants must be fairly proficient at using the internet and
have the required writing and reading skills for using the
program, in addition to the obvious requirement for
convenient internet access. In our study, 14 patients who
were offered participation failed to go through the enrollment
progress, and some of these could be due to lack of computer
or writing skills.
Feedback from doctors and secretaries involved in the
study was very positive. It was agreed that the program could
potentially help to better utilize the scarce dietician resources
by decreasing the need for consulting face to face. In relation
to the implementation in the medical centers, it was
important that there should be a technical integration that
makes the internet portal an integrated part of the electronic
journal system used by the Danish National Health Service.
Communication between the medical center and dieticians
could become an integrated part of the doctors daily work
tool. It is especially necessary to establish a technical
integration with billing and information exchange, to
minimize the need for intervention by the other staff at the
medical center.
With a total of 500 licensed dieticians in Denmark and
approximately 50 newly educated every year, faced with the
needs of 4000 medical centers to provide relevant treatment
offers to ever increasing numbers of obese patients, the
27
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org

present pilot trial indicates the potential usefulness of this
type of effective and economically attractive individual
internet treatment for the large part of the population in need
of dietary advice.
V. CONCLUSION AND FUTURE WORK
The study showed that the internet based interactive weight
management program may be a cost-effective way to
produce a significant and sustained weight loss among
patients with obesity in general practice. The internet can be
used as a communication tool for lifestyle changes and
provide a community for the patients to support them to
maintain weight loss and healthier life style. We have
developed a protocol for a randomized controlled trial to
further investigate the efficacy of this weight-loss program in
a more controlled setting, comparing the intervention with
usual care [18]. Furthermore, we are working on a
refinement of the internet platform to record how much each
of the participants use the internet community, as a tool to
assess the importance of this feature.
ACKNOWLEDGMENT
Thanks to medical student Mathilde Pedersen, University
of Southern Denmark and to political science student Sara
Katrine Brandt for editorial contributions to this paper.
Thanks to the staff at Stenstrup Lægehus, Nyenstadlægerne
and Marstal Lægehus for making this study possible. Thanks
to Region Syddanmark and the KEU fund for input and
financial support.
REFERENCES
[1] C. J. Brandt, C. Arendal, D. Glintborg, S. Toubro, "e-Dietician in
General Practice," etelemed, pp.29-32, 2010 Second International
Conference on eHealth, Telemedicine, and Social Medicine, 2010
[2] A. Peeters, J. J. Barendregt, F. Willekens, J. P. Mackenbach, M. A.
Al, and L. Bonneux. Obesity in adulthood and its consequences for
life expectancy: a life-table analysis. Ann Intern Med 2003 Jan
7;138(1):24-32.
[3] C. J. Brandt, H. Ellegaard, M. Joensen, F. V. Kallan, A. D. Sorknæs,
and L. Tougaard. Effect of diagnosis of "smoker's lung". RYLUNG
Group. Lancet 1997 Jan 25;349(9047):253.
[4] R. L. Thompson, C. D. Summerbell, L. Hooper, J. P. Higgins, P. S.
Little, D. Talbot et al. Dietary advice given by a dietitian versus other
health professional or self-help resources to reduce blood cholesterol.
Cochrane Database Syst Rev 2003;(3):CD001366.
[5] M. Neve, P. J. Morgan, P. R. Jones, and C. E. Collins. 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):306-21.
[6] B. Richelsen, A. Astrup, G. L. Hansen, H. S. Hansen, B. Heitmann,
L. Holm, et al. A report from the board of Nutrition. The Danish
epidemic of obesity – Proposal for a prevention effort . 2003.
[7] T. J. Moore, N. Alsabeeh, C. M. Apovian, M. C. Murphy, G. A.
Coffman, D. Cullum-Dugan, et al. Weight, blood pressure, and
dietary benefits after 12 months of a Web-based Nutrition Education
Program (DASH for health): longitudinal observational study. J Med
Internet Res 2008;10(4):e52.
[8] D. J. Wantland, C. J. Portillo, W. L. Holzemer, R. Slaughter, and E.
M. McGhee. The effectiveness of Web-based vs. non-Web-based
interventions: a meta-analysis of behavioral change outcomes. J Med
Internet Res 2004 Nov 10;6(4):e40.
[9] R. A. Winett, D. F. Tate, E. S. Anderson, J. R. Wojcik, and S. G.
Winett. Long-term weight gain prevention: a theoretically based
Internet approach. Prev Med 2005 Aug;41(2):629-41.
[10] B. C. Gold, S. Burke, S. Pintauro, P. Buzzell, and J. Harvey-Berino.
Weight loss on the web: A pilot study comparing a structured
behavioral intervention to a commercial program. Obesity (Silver
Spring) 2007 Jan;15(1):155-64.
[11] D. F. Tate, R. R. Wing, and R. A. Winett. Using Internet technology
to deliver a behavioral weight loss program. JAMA 2001 Mar
7;285(9):1172-7.
[12] J. Harvey-Berino, S. Pintauro, P. Buzzell, and E. C. Gold. Effect of
internet support on the long-term maintenance of weight loss. Obes
Res 2004 Feb;12(2):320-9.
[13] H. A. Haugen, Z. V. Tran, H. R. Wyatt, M. J. Barry, and J. O. Hill.
Using telehealth to increase participation in weight maintenance
programs. Obesity (Silver Spring) 2007 Dec;15(12):3067-77.
[14] L. P. Svetkey, V. J. Stevens, P. J. Brantley, L. J. Appel, J. F. Hollis,
C. M. Loria, et al. Comparison of strategies for sustaining weight
loss: the weight loss maintenance randomized controlled trial. JAMA
2008 Mar 12;299(10):1139-48.
[15] Statistics Denmark. Internet access in the home - devices with access
to internet. http://www.statistikbanken.dk/BEBRIT01 (accessed
January 2
nd
, 2010).
[16] G. G. Bennett, S. J. Herring, E. Puleo, E. K. Stein, K. M. Emmons,
and M. W. Gillman. Web-based weight loss in primary care: a
randomized controlled trial. Obesity (Silver Spring) 2010
Feb;18(2):308-13.
[17] SlankeDoktor. www.slankedoktor.dk. (accessed January 2
nd
, 2011)
[18] V. Brandt, M. Pedersen, C. J. Brandt, C. Arendal, D. Glintborg, S.
Toubro, K. Brandt "Design and aims of study to measure long-term
efficacy of interactive online diatician weight loss advice in general
practice," etelemed, 2011 Third International Conference on eHealth,
Telemedicine, and Social Medicine, 2011
28
International Journal
o
n Advances in
Life
Sciences
, vol
3
no
1
&
2
, year 20
1
1
,
http://www.iariajournals.org/life_sciences
/
201
1
, © Copyright by authors, Published under agreem
ent with IARIA
-
www.iaria.org