Innovating against Obesity: Applying Social Networking

Services to Manage Body Mass Index Following the World

Innovation Summit for Health Policy

Hutan Ashrafian*, Tania Toma, Leanne Harling, Karen Kerr,

Thanos Athanasiou and Ara Darzi

Institution:

1The Department of Surgery and Cancer, Imperial College London,

10th Floor Queen Elizabeth the Queen Mother (QEQM) Building, St

Mary’s Hospital, Praed Street, London, W2 1NY, UK

*Correspondence to:

Dr Hutan Ashrafian

The Department of Surgery and Cancer,

Imperial College London,

10th Floor Queen Elizabeth the Queen Mother (QEQM) Building,

St Mary’s Hospital,

Praed Street, London, W2 1NY, UK

h.ashrafian@imperial.ac.uk

Tel: +44(0) 203 3127651; Fax: +44(0) 203 3126309

Word Count: 4066 (including title page, abstract, tables and

references)

Funding Statement: This research was funded by the Qatar

Foundation

Abstract

The global epidemic of obesity continues to escalate. It

represents an increasing proportion of the international

socio-economic burden of non-communicable disease (NCD) that

was addressed at the 2013 World Innovation Summit for Health

(WISH). Global online social networking services (SNS) provide

a prevailing communication medium through which information

may be exchanged between obese and overweight patients and

their healthcare providers, potentially contributing to

superior weight-loss outcomes. We performed a systematic

review and meta-analysis to appraise the role of SNS in the

global management of obesity through its effect on modifying

Body Mass Index (BMI). Our results demonstrate that SNS

interventions may produce a significant, but modest 0.64%

reduction in BMI. As a result, we offer specific

recommendations for the integration of this global

communicative technology into policy-driven public health

reforms in order to facilitate multi-stakeholder partnerships

and create a supportive environment to tackle obesity and its

associated NCDs.

Key Words: ‘Social Networking Services’; ‘Obesity’;

‘Innovation’; ‘Health Policy’

Abstract Word Count: 148

Introduction

The global epidemic of obesity continues to escalate and

represents an increasing proportion of the substantial

international socio-economic burden of non-communicable

disease (NCD). Decades of caloric overconsumption combined

with reduced energy expenditure has produced an ‘obesogenic’

environment, causing the global prevalence of obesity to

double since 1980.(1) Similarly, these environmental forces

are driving a concomitant rise in diabetes, cardiovascular

disease, mental health and cancer, placing additional strain

on global heath services particularly in already overburdened

low- and middle- income countries. Although increased

consumption may have a positive effect on global GDP,

increased disease related expenditure negates the benefit of

higher consumption and the associated loss of productivity

negatively impacts on economic growth. As such, obesity has

become a disease of poverty, exaggerated by the high costs of

fresh produce and plentiful access to cheap and unhealthy food

choices.

An obesity policy forum convened in conjunction with the 2013

World Innovation Summit for Health (WISH) in Doha presented an

agenda for strategic action on this global problem. This

highlighted the current and predicted future global status of

obesity to identify key recommendations for ministers for

health (Technical appendix - Table 1), policy makers and

health providers.(2) It is currently estimated that obesity

and associated NCDs consume approximately 6% of the global

healthcare budget, and that for every 1 point increase in BMI

above 30, individual healthcare expenditure increases by 8%.

(3) Worrying trends from the United States also highlight the

potential scale of this problem without intervention;

estimating the total economic cost of obesity to reach $957

billion by 2030, accounting for 18% of US health expenditure.

(4) Addressing the global obesity crisis requires a whole-

population approach if we are to achieve the World Health

Assembly target of 0% global growth in obesity by 2025.(5)

This will necessitate collaboration between policy-makers and

health systems, as well as multi-stakeholder partnerships with

industry, private and public sectors.

Tackling obesity also demands a coordinated timeline of

intervention, combining short-term treatments with long-term

re-education. Government initiatives such as fiscal and trade

policy supporting healthy imports and domestic food

production, alongside the implementation of food labeling

standards go some way to shift societal norms and promote

healthy food choices.(2) However, additional social support

will be required to achieve long-term weight reduction.(6, 7)

As such, primary care physicians are expected to play an

increasing role in future obesity management strategies

through lifestyle counseling and intervention. However,

primary care resources are already oversubscribed and

substantial manpower and funds would be required for this to

be implemented. Consequently, it is vital that community based

treatments are integrated into any sustainable long-term and

cost-effective strategy to combat obesity. Furthermore,

community action groups and local/work place support networks

may also provide obese patients with an individualized social

framework, subsequently improving weight loss outcomes by

setting personalized, locally appropriate targets.

Computer and web-based technologies may also offer innovative

approaches to deliver weight loss programmes, and allow us to

impact on healthcare at a population level. Furthermore, these

technologies also offer potential to engage support for

environmental and policy changes that are essential to obesity

prevention. Existing web-based interventions have generally

adopted behavioural and cognitive restructuring strategies

through education, self-monitoring and goal setting.(8) Whilst

this has been partially effective, social networking services

(SNS) now provide a more multi-faceted approach, allowing us

to integrate online community networks and access to

healthcare providers through instant messaging and secure chat

forums. This novel approach offers improved accessibility as

online services can be used at any time of day, with greater

anonymity when compared to face-to-face contact. It also

offers the opportunity to improve data collection, and provide

detailed analysis.

SNS may be defined as “web-based services that allow

individuals to (1) construct a public or semi-public profile

within a bounded system, (2) articulate a list of other users

with whom they share a connection, and (3) view and traverse

their list of connections and those made by others within the

system”.(9) Already utilised in a number of chronic diseases,

SNS have become increasingly popular given the rapid uptake of

mobile phones and tablet devices.(10, 11) Current examples

include the Nutri-Expert system(12) and the online

CalorieKing™ website (http://www.calorieking.com. au),(13)

however the exact nature of this intervention presently varies

according to the region or institution. By exploiting the

expanding technology of global online social networking, SNS

offers a potentially cost-effective population-based means by

which we may both treat and prevent obesity and its associated

NCDs. Furthermore, these novel services allow for additional

features such as personalized feedback, decision advice and

peer-support forums to be provided real-time, delivering a

uniquely contextual and individualized intervention.

SNS technologies have recently shown encouraging results in

patients with Diabetes Mellitus producing positive metabolic

outcomes and improvements in both blood pressure and glycaemic

control.(14) However, when orientated to achieve weight loss,

previous studies of web-based interventions demonstrate more

modest results.(15, 16) One fundamental limitation to current

reviews of this literature is the use of weight-loss as a

primary outcome rather than BMI, producing a high degree of

heterogeneity given the wide range of starting weights and

body morphologies of overweight and obese patients. As such,

an accurate appraisal of the role of SNS interventions in

tackling obesity remains lacking. Although we recognise that

BMI also has its limitations as an outcome measure in that it

does not take into account lean muscle mass or body fat

distribution, it remains to be a globally accepted measure of

obesity in view of its universality and practical

calculability. The objective of this study is therefore to

review the role of SNS interventions in the management of

obese and overweight patients. We will begin by assessing the

effect of online social networking services (SNS) in achieving

beneficial reductions in BMI through a comprehensive meta-

analysis of published randomised controlled studies. Based on

these findings, we will then discuss the application of SNS

and how it may influence global healthcare. Finally, we will

conclude by providing policy recommendations regarding the

incorporation of SNS into public health reforms that strive to

combat the global epidemic of obesity.

Methods

A systematic search of MEDLINE (1946 to present), EMBASE (from

1974 to present) and PSYCHINFO (from 1967 to present) was

performed using the MeSH terms: "social networking”, “BMI”,

“obesity”, “overweight”, “weight loss,” “weight change,” “body

mass index”, “mobile phone", "cellular phone", "text message",

"smart phone", “SMS”, “web”, “web-based”, “internet” and

“internet-based”. Meta-analysis was performed using a random

effects model. A summary of the search strategy is shown in

the Technical Appendix, Figure 1.

Exclusion Criteria

Studies were excluded if: (1) BMI was not used as an outcome

measure; (2) the intervention group was not compared with a

control; (3) they were non-randomised studies or reviews, case

reports, comments or editorials; (4) they involved the use of

non-wireless technology e.g. telephone lines, as the primary

method of communication and exchange of data and (5) they

included participants with a normal BMI.

This meta-analysis was conducted in accordance with PRISMA

(Preferred Reporting Items for Systematic Reviews and Meta-

Analyses) guidelines(17) and written in line with

recommendations from the Cochrane Collaboration. Statistical

analysis was carried out using Review Manager® Version 5.0 for

Windows (The Cochrane Collaboration, Software Update, Oxford,

UK) and STATA v.11 statistical analysis software.

Continuous outcome data from individual studies was analysed

using a random effects model. Weighted mean difference (WMD)

was used as the summary statistic for continuous variables and

reported with 95% confidence intervals (CI). Point estimates

with a p-value <0.05 were considered statistically significant

providing the 95% confidence interval did not include the

value zero. Odds ratio (OR) was used to analyse categorical

data. An OR of <1 favoured the intervention group and was

considered statistically significant at p<0.05 providing the

95 % confidence interval did not include the value 1.

Between-study heterogeneity was calculated using the I2

statistic. Significant statistical heterogeneity was regarded

as present where I2 was greater than 50%.

A full description of study selection criteria, assessment of

study quality and potential bias was performed as described in

Technical Appendix 1.

Limitations

It is important to also consider a number of limitations when

evaluating this data. Firstly, the studies included in our

analysis are of small size and provide limited long-term

follow-up. This is particularly notable in that only two

studies report data at 12-months(12, 18). Secondly, although

we believe BMI is a superior outcome measure to weight-loss,

it may be criticised for not taking into account lean muscle

mass or body fat distribution, which may vary particularly

across gender and ethnic groups. Third, all included studies

focus on primary health outcomes such as BMI, waist

circumference and blood pressure. At present there is little

evidence regarding the effect of SNS on intermediate outcome

measures such as caloric intake or time spent on exercising.

Further evaluation of these parameters may provide better

insight into whether SNS does indeed produce recordable

behavioural changes.

It is also notable that although previous research suggests

that computer-based support may incur considerably lower cost

than in-person alternatives,(19) there is a lack of robust

evidence assessing the cost-effectiveness of SNS and its

viability in obesity care. Thus, it is necessary for policy

makers to account for this inadequacy, along with

considerations over the safety, sustainability, and

scalability of SNS before confirming it as an effective

therapy for obesity and overweight.(20)

It is also important to consider the potential disadvantages

of SNS technologies. Compared to face-to-face contact with

healthcare providers or even real-life participation in group-

programs, SNS may provide a more abstract patient-provider

interaction and thus result in a less individualized and

detached treatment approach. Furthermore, the Internet, and

particularly groups of ‘lay experts’, can be important

mechanisms for disseminating misinformation. Mitigating this

risk would require active moderation by a health expert, which

may create some extra burden on healthcare providers.

Additionally, although peer-support groups can be hugely

motivating, the relative anonymity offered by online

technologies also creates a risk of cyber-bullying when

participants do not meet group goals. Such negative emotional

impacts can result in achieving the opposite effect of that

intended and deter people from future participation in weight

management programs.

Finally, where SNS strategies are implemented, it is important

to ensure equity of care amongst all socio-economic classes.

This is of particular importance in the lower socio-economic

classes, in whom levels of obesity are likely to have an

inverse correlation with level of education and likelihood of

computer literacy. Similarly, SNS technologies should ideally

also be made available to economically weaker strata of the

population, where computers and smartphones are less likely to

be affordable. It is therefore important to consider the risk

of increasing health inequities when implementing SNS on a

wider scale, and future policy decisions should include a

discussion as to potential strategies that may mitigate such

risks in the future.

Results

Twelve studies were assessed comprising a pooled data set of

1884 patients, 941 of whom received SNS intervention

predominantly through Internet platforms. Prior to SNS

intervention, baseline BMI was comparable between SNS and

control patients.

Characteristics of Interventions

The Internet, particularly through interactive websites, was

the predominant platform used. Nine trials solely used web-

based tools(12, 13, 18, 21-26), 1 study combined Internet and

mobile technology,(27) and 2 studies integrated the Internet

with telephone communication.(28, 29) Two studies adopted

supplementary armbands with real-time electronic displays of

results(28, 29), one provided a wristwatch with a similar type

of display,(29) and one study provided participants with

pedometers.(18)

Nine studies delivered personalised feedback to participants

based on their online data.(12, 13, 18, 23, 24, 26-29). This

feature was enhanced in 5 studies by direct messaging with

providers via secure SMS, email or online chat-rooms.(12, 18,

21, 23, 27) Another defining feature occurring in 4 studies

was the use of online peer support and group discussion forums

as a communal space for interaction between participants.(21-

23, 25) In an additional study, providers were present

alongside participants in the online forums.(12) Five studies

incorporated goal-setting modules to encourage anti-obesity

actions(18, 25, 26, 28) and 4 provided online journals where

participants regularly documented a range of personal data

including physical and nutritional activity, weight, energy

expenditure and calorie consumption.(13, 23-25) Three studies

had an online education element delivering non-personalised

advice on nutrition, exercise and healthy living.(18, 22, 25)

Effect of SNS Interventions

After completing the intervention period, SNS patients had a

significantly lower BMI than control patients (0.64% lower)

and experienced a significantly greater change in BMI from

baseline (-0.66%). SNS also lead to a 1.40% greater reduction

in body weight and 0.79% greater reduction in waist

circumference than control patients although this did not

reach statistical significance. SNS interventions did not

however result in any significant changes in metabolic markers

such as body fat percentage, blood pressure or lipid profiles.

When considering the duration of SNS interventions, the

optimal period of intervention was found to be between six and

twelve months. Where follow-up was less than 6 months or

greater than 12 months, no significant effect on BMI was

observed.

A complete report of the meta-analysis methodology and results

is described in detail in Technical Appendix 1.

Discussion

This study demonstrates that SNS technologies may facilitate a

modest yet significant reduction in BMI in obese and

overweight individuals. As expected, these effects are

gradual, reaching significance when SNS interventions are

continued for 6 months or more. However, the impact of SNS on

BMI reduction appears less significant after 12 months,

suggesting that compliance may be a factor in achieving a

long-term, sustainable reduction in BMI. In accordance with

previous findings,(15, 16) this study did not demonstrate any

commensurate significant reductions in weight, waist

circumference, adiposity, blood pressure or lipid profiles in

these patients. These findings were independent of the length

of SNS intervention program.

With 82% of the world’s online population over 15 years of age

engaging in social networking activities,(30) SNS offers a

means whereby we may impact on healthcare at a global level to

broadcast and disseminate medical information across vast

virtual audiences.(31) Fundamentally, SNS acts not only as a

passive tool whereby information may be disseminated, but also

provides an adjunctive real-time, participatory communication

medium through features such as instant messaging services and

online support forums.

SNS strategies largely focus on targeting lifestyle patterns

to mitigate obesogenic behavior and achieve favourable

improvements in BMI. Through the enforcement of online goal

setting, journals and self-monitoring tools, patients are

empowered to adopt a more independent approach to self-care.

(32) Crucially, SNS provides social support through digital

communities, offering group encouragement as well as an

individualized interaction between patients and providers, and

exchange of personal data and recommendations.

As with other dietary and lifestyle weight-loss interventions,

patients do however become less responsive to SNS in the long

term, with even smaller reductions in BMI after an

intervention period beyond 12-months. One of the challenges of

SNS is therefore to maintain participant engagement in order

to achieve long-term weight reduction(12). Over time, patients

may develop tolerance and even boredom towards the various

stimuli provided by SNS.(15) Furthermore, SNS systems are

often blamed for being overly complex and time-consuming,(22,

24) decreasing long-term compliance. As such, in order to

optimize SNS technologies in obesity healthcare it is

important to create a simple, user-friendly, system that is

accessible to all patient groups.

Mobile phone and tablet devices provide one means by which we

may augment Internet based programs and improve the

portability of existing SNS systems. In addition, despite

early concerns regarding the privacy and confidentiality of

data exchange, social networking giants such as Facebook® or

Twitter may provide a familiar and practical approach to

initiate online connections between communities of physicians

and patients. Indeed, through use of a private online

Facebook® group within which participants were given caloric

targets, goal setting advice and online ‘buddies’; Facebook

has been shown to offer the potential to augment conventional

SNS interventions (33).

The results presented here highlight the potential for SNS to

contribute to the global strategy on tacking obesity by

offering a cost-effective means to augment existing policies

that address overconsumption and promote physical activity.

Furthermore, SNS platforms may be utilized in a similar way to

tackle many obesity associated non-communicable diseases

including diabetes, hypertension, and heart disease. As such,

social media presents a novel, accessible and realistic tool

to monitor both individual and population health in homes,

workplaces, schools and colleges. The flexibility of SNS also

allows for individual customization, with the setting of

specific targets according to the local culture and

environment. However, despite the aforementioned benefits of

SNS technologies, these initiatives must be considered as

adjuncts to a much wider, multi-faceted strategy on obesity

that requires multi-stakeholder partnerships between

governments, industry, private and public sectors.

Recommendations

The recent report from the World Innovation Summit for Health

(WISH) held in Doha in December 2013 addresses the key drivers

of obesity and outlines recommendations to tackle this ever

increasing problem in both the short- and long- term

(Technical appendix - Table 4).(2)

The key recommendations from this summit aim to champion the

issue of obesity and for policy makers to become ambassadors

for change. Beyond this, they highlight the importance of

finding innovative and economically viable ways to address

obesity-promoting forces in the food environment, with an

emphasis placed on learning from successes in similar

countries. Finally, these recommendations advise settings-

based initiatives in at least one of three core societal

institutions (schools, worksites and healthcare), with the

other institutions to follow in future years.(2)

Based on the results of this study we suggest a number of

additional SNS specific proposals. Firstly, we recommend the

implementation of a series of large scale randomised

controlled clinical trials to evaluate the impact of SNS on

BMI reduction with follow-up extended into the long-term to

assess 5- and 10- year outcomes. Furthermore, such studies

should include an adjunctive full cost-effectiveness

evaluation to determine the economic viability of scaling up

SNS interventions.

We also recommend the early implementation of SNS as an

adjunctive tool for measuring and monitoring obesity and the

metabolic syndrome in obese and overweight patients.

Furthermore, we recommend that social media platforms be

applied to the coordination of obesity treatment and

prevention services at planning and operational levels. This

should include social networks, nutritional guidance, physical

activity and behavioural support.

Importantly, in order to advance social networking service

technologies, SNS should now be developed to allow the

integration of social media hubs as portals for the

dissemination of anti-obesity treatment supervision, support

and guidance. Furthermore, this should be made applicable to a

variety of platforms including mobile applications (mHealth

Technologies), with a subsequent assessment made of the

relative effectiveness of each SNS platform by means of

further large scale appropriately designed randomised clinical

trials. Finally, effective social media interventions should

be ‘scaled up’ and both healthcare and community support staff

trained to provide anti-obesity SNS interventions to their

patients.

Conclusions

In summary, online social networking services (SNS) may

provide an accessible, cost-effective means of achieving

beneficial reductions in BMI. As such, SNS may augment policy-

driven public health reforms to combat the global epidemic of

obesity within school, workplace and healthcare environments.

Beyond weight loss, by utilising SNS platforms in NCDs such as

diabetes, hypertension, and heart disease, online technologies

may support the development of individualized metabolic

syndrome management programs through the integration of multi-

disciplinary services. Furthermore, through data collection

and focused research, enhanced applications of social media

platforms may help coordinate government, private and public

sectors in planning strategies for obesity treatment and

prevention.

Further research and developments are now necessary for SNS to

be developed into a clinically viable option in obesity and

overweight care. One of the key challenges faced by developers

is in ‘scaling-up’ effective social media interventions to

deliver a more portable, user-friendly service that integrates

mobile phones, tablet devices and popular online social

networking sites whilst maintaining participant

confidentiality and security. At the same time, increases in

SNS delivery must be coupled with the provision of expertly

trained staff to provide these interventions and facilitate

public engagement.

Whilst these and other challenges undoubtedly lie ahead, this

global communicative technology provides a valuable

opportunity for action on obesity and its associated NCDs,

with the potential to facilitate multi-stakeholder

partnerships and create supportive environments to combat

obesity. In this way we believe SNS technologies may augment

the policy-driven public health reforms of the future, and

form a keystone in tomorrows checklist to tackle the global

epidemic of obesity.

Acknowledgments: We would like to thank the panel members of

the World Innovation Summit for Health (WISH) Obesity Forum

for their invaluable contribution to this work: Shiriki

Kumanyika – University of Pennsylvania & International Obesity

Task Force and Chair of the WISH Obesity Forum; Javaid Sheikh

– Dean, Weill Cornell Medical School; Maryah B. Al-Dafa –

Project Director in the Office of President of Qatar

Foundation.

Funding: This research was funded by the Qatar Foundation

Conflict of Interest: None

References

1. WHO. Obesity and overweight: Fact Sheet No. 311. 2013

[cited 2014 12 March 2014]; Available from:

http://www.who.int/mediacentre/factsheets/fs311/en/index.html.

2. Kumanyika S, Libman K, Garcia A. Strategic Action to

Combat the Obesity Epidemic. Report of the Obesity Working

Group 2013. 2013 10-11th December.

3. Algazy J, Gipstein S, Riahi F, Tryon K. Why governments

must lead the fight against obesity. 2010 October.

4. American Heart Association (AHA). Overweight and Obesity:

Statistical Fact Sheet 2013 Update. American Heart Association

2013 [cited 2014 12 March]; Available from:

http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/do

cuments/downloadable/ucm_319588.pdf.

5. World Health Orgaisation (WHO). A comprehensive global

monitoring framework, including indicators, and a set of

voluntary global targets for the prevention and control of

noncommunicabale diseases: World Health Organisation. 2012

25th July.

6. Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle

modification for long-term weight control. Obesity research.

2004 Dec;12 Suppl:151S-62S.

7. Hill JO, Thompson H, Wyatt H. Weight maintenance: what's

missing? Journal of the American Dietetic Association. 2005

May;105(5 Suppl 1):S63-6.

8. Chen JL, Weiss S, Heyman MB, Cooper B, Lustig RH. The

efficacy of the web-based childhood obesity prevention program

in Chinese American adolescents (Web ABC study). The Journal

of adolescent health : official publication of the Society for

Adolescent Medicine. 2011 Aug;49(2):148-54.

9. Boyd D, Ellison N. Social Network Sites: Definition,

History, and Scholarship. Journal of Computer-Mediated

Communication. 2007;13(1):article 11.

10. Greene JA, Choudhry NK, Kilabuk E, Shrank WH. Online

social networking by patients with diabetes: a qualitative

evaluation of communication with Facebook. Journal of general

internal medicine. 2011 Mar;26(3):287-92.

11. Liaw ST, Lau A, Dennis S. General practice - engaging the

online social networking revolution. Australian family

physician. 2010 Nov;39(11):809-10.

12. Turnin MC, Bourgeois O, Cathelineau G, Leguerrier AM,

Halimi S, Sandre-Banon D, et al. Multicenter randomized

evaluation of a nutritional education software in obese

patients. Diabetes & metabolism. 2001 Apr;27(2 Pt 1):139-47.

13. Morgan PJ, Callister R, Collins CE, Plotnikoff RC, Young

MD, Berry N, et al. The SHED-IT community trial: a randomized

controlled trial of internet- and paper-based weight loss

programs tailored for overweight and obese men. Annals of

behavioral medicine : a publication of the Society of

Behavioral Medicine. 2013 Apr;45(2):139-52.

14. Toma T, Athanasiou T, Harling L, Darzi A, Ashrafian H.

Online Social Networking Services in the Management of

Patients with Diabetes Mellitus: Systematic Review and Meta-

Analysis of Randomised Controlled Trials. Accepted Diabetes

Research and Clinical Practice, In Press, July 2014.

15. Kodama S, Saito K, Tanaka S, Horikawa C, Fujiwara K,

Hirasawa R, et al. Effect of Web-based lifestyle modification

on weight control: a meta-analysis. International journal of

obesity. 2012 May;36(5):675-85.

16. 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. Obesity reviews : an official

journal of the International Association for the Study of

Obesity. 2010 Apr;11(4):306-21.

17. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P.

Preferred reporting items for systematic reviews and meta-

analyses: the PRISMA statement. Annals of internal medicine.

2009 Aug 18;151(4):264-9, W64.

18. Patrick K, Calfas KJ, Norman GJ, Rosenberg D, Zabinski

MF, Sallis JF, et al. Outcomes of a 12-month web-based

intervention for overweight and obese men. Annals of

behavioral medicine : a publication of the Society of

Behavioral Medicine. 2011 Dec;42(3):391-401.

19. Wylie-Rosett J, Swencionis C, Ginsberg M, Cimino C,

Wassertheil-Smoller S, Caban A, et al. Computerized weight

loss intervention optimizes staff time: the clinical and cost

results of a controlled clinical trial conducted in a managed

care setting. Journal of the American Dietetic Association.

2001 Oct;101(10):1155-62; quiz 63-4.

20. Car J, Huckvale K, Hermens H. Telehealth for long term

conditions. Bmj. 2012;344:e4201.

21. Bennett GG, Herring SJ, Puleo E, Stein EK, Emmons KM,

Gillman MW. Web-based weight loss in primary care: a

randomized controlled trial. Obesity. 2010 Feb;18(2):308-13.

22. Carr LJ, Bartee RT, Dorozynski C, Broomfield JF, Smith

ML, Smith DT. Internet-delivered behavior change program

increases physical activity and improves cardiometabolic

disease risk factors in sedentary adults: results of a

randomized controlled trial. Preventive medicine. 2008

May;46(5):431-8.

23. Doyle AC, Goldschmidt A, Huang C, Winzelberg AJ, Taylor

CB, Wilfley DE. Reduction of overweight and eating disorder

symptoms via the Internet in adolescents: a randomized

controlled trial. The Journal of adolescent health : official

publication of the Society for Adolescent Medicine. 2008

Aug;43(2):172-9.

24. Hunter CM, Peterson AL, Alvarez LM, Poston WC, Brundige

AR, Haddock CK, et al. Weight management using the internet a

randomized controlled trial. American journal of preventive

medicine. 2008 Feb;34(2):119-26.

25. Jones M, Luce KH, Osborne MI, Taylor K, Cunning D, Doyle

AC, et al. Randomized, controlled trial of an internet-

facilitated intervention for reducing binge eating and

overweight in adolescents. Pediatrics. 2008 Mar;121(3):453-62.

26. Kraschnewski JL, Stuckey HL, Rovniak LS, Lehman EB, Reddy

M, Poger JM, et al. Efficacy of a weight-loss website based on

positive deviance. A randomized trial. American journal of

preventive medicine. 2011 Dec;41(6):610-4.

27. Yoo HJ, Park MS, Kim TN, Yang SJ, Cho GJ, Hwang TG, et

al. A Ubiquitous Chronic Disease Care system using cellular

phones and the internet. Diabetic medicine : a journal of the

British Diabetic Association. 2009 Jun;26(6):628-35.

28. Pellegrini CA, Verba SD, Otto AD, Helsel DL, Davis KK,

Jakicic JM. The comparison of a technology-based system and an

in-person behavioral weight loss intervention. Obesity. 2012

Feb;20(2):356-63.

29. Shuger SL, Barry VW, Sui X, McClain A, Hand GA, Wilcox S,

et al. Electronic feedback in a diet- and physical activity-

based lifestyle intervention for weight loss: a randomized

controlled trial. The international journal of behavioral

nutrition and physical activity. 2011;8:41.

30. comScore. It’s a Social World: Top 10 Need-to-Knows About

Social Networking and Where It’s Headed: comScore. 2011 21

December.

31. Wake DJ, Cunningham SG. ‘Digital Diabetes’- Looking to

the Future. The British Journal of Diabetes and Vascular

Disease. 2013;13(1):13-20.

32. Piette JD. Interactive behavior change technology to

support diabetes self-management: where do we stand? Diabetes

care. 2007 Oct;30(10):2425-32.

33. Napolitano MA, Hayes S, Bennett GG, Ives AK, Foster GD.

Using Facebook and text messaging to deliver a weight loss

program to college students. Obesity. 2013 Jan;21(1):25-31.