Original Article
Weight Problems and Spam E-mail for Weight
Loss Products
Joshua Fogel,
PhD,
and Sam Shlivko,
BS
Background: This study focuses on young adult behaviors with
regard to spam e-mails that sell weight loss products.
Methods: Participants (N ⫽ 200) with and without weight problems
were asked if they received, opened, and bought products from spam
e-mail about weight loss topics in the past year. Psychological factors of self-esteem and perceived stress were measured.
Results: Those with weight problems had significantly greater percentages than those without weight problems for receiving (87.7%
vs. 73.3%, P ⫽ 0.02), opening (41.5% vs. 17.8%, P ⬍0.001), and
buying products (18.5% vs. 5.2%, P ⫽ 0.003). In the multivariate
logistic regression analyses, weight problems were significantly associated with receiving (OR: 3.39, 95% CI: 1.31, 8.82), opening
(OR: 3.10, 95% CI: 1.53, 6.29), and buying products (OR: 3.38,
95% CI: 1.16, 9.82).
Conclusion: Physicians should consider discussing with patients the
potential risks of opening and/or purchasing weight loss products
from spam e-mails.
Key Words: body weight, electronic mail, internet, obesity, weight
loss
S
pam e-mail on health and pharmaceutical topics are received by over 80% of individuals.1 In a 2007 survey, the
Pew Internet and American Life Project reported that most
e-mail users are bothered by spam with 18% believing that it
is a big problem and 51% believing that it is annoying.2
Another study reported that 81% of individuals “strongly
dislike” spam and 14% simply just “dislike” spam.3
Spam e-mails are sent with the intent for recipients to open
them and to be interested in the message content of that spam
e-mail. Purchases from spam e-mail solicitations range from as
low as 4% to as high as 66% depending upon the study.1–5 Older
From the Department of Economics, Brooklyn College, Brooklyn; and New
York Law School, New York, NY.
Reprint requests to Joshua Fogel, PhD, Department of Economics, Brooklyn
College of the City University of New York, 218A, 2900 Bedford Avenue, Brooklyn, NY 11210. Email: [email protected]
Accepted April 14, 2009.
Copyright © 2010 by The Southern Medical Association
0038-4348/0⫺2000/10300-0031
Southern Medical Journal • Volume 103, Number 1, January 2010
retirement-age individuals are more likely to purchase from solicitations in spam e-mail than college-age young adults.3
Almost one-third of spam e-mail consists of health-related
messages.6 Spam e-mail marketing of health products appeals to
the perceived health needs of individuals. Weight loss topics are
of great importance to young adults and spam e-mails about
weight loss are commonly sent to young adults. There are also
psychological concerns related to dissatisfaction with one’s
weight that can include low self-esteem7 and increased perceived
stress.8,9 These psychological concerns may make young adults
susceptible to buy products from spam e-mail weight loss solicitations.
To our knowledge, we are the first to study young adult
responses to spam e-mail selling weight loss products. We
have four hypotheses. First, the presence of weight problems
among young adults is associated with receiving spam e-mail
about weight loss topics at greater levels than those without
weight problems. Spam is not always randomly sent to all
individuals with an e-mail address. Individuals with weight
problems may have previously provided their e-mail address
when they requested information or purchased weight loss
products from internet vendors. These e-mail addresses may
be used by this particular company or sold to other companies
who now send spam e-mail to these individuals. Individuals
who do not have weight problems are not as likely to have
provided their e-mail address to internet vendors selling
weight loss products. Second, the presence of weight problems among young adults is associated with opening spam
e-mail about weight loss topics at greater levels than those
without weight problems due to greater interest in weight
loss. Third, the presence of weight problems among young
adults is associated with buying products from spam e-mail
about weight loss topics at greater levels than those without
weight problems due to greater interest in weight loss. Fourth,
the psychological concerns of low self-esteem and increased
perceived stress, which are often associated with being overweight, is associated with the receiving of, opening of, and
buying products from spam e-mail about weight loss topics.
Materials and Methods
Participants and Procedures
Participants were 200 students from a 4-year undergraduate commuter college in New York City. Of 212 students
31
Fogel and Shlivko • Spam E-mail and Weight Loss
approached, 200 completed surveys for a response rate of
94.3%. The sample was a convenience sample. Participants
were approached to complete an anonymous survey in classrooms, the school cafeteria, the library, and other public
places. Informed consent was obtained. The survey was exempt from Institutional Review Board review and was conducted in accordance with the ethical principles of the Declaration of Helsinki. Data collection occurred during May
2007.
Measures
Demographics. Demographic variables included age
(years), sex, race/ethnicity (white, non-white), hours of internet use (daily), and number of spam e-mails received (daily).
Weight problems item. Participants were asked, “Do you
believe that you have weight problems?” with choices of
“yes” or “no.”
Spam e-mail items. These items were: 1) Did you receive spam e-mail about weight loss in the past year? 2) If
yes, did you open and read the e-mail? 3) If you opened and
read the e-mail, did you buy anything from the website provided?
Psychological Questionnaires
Rosenberg Self-Esteem Scale. The Rosenberg Self-Esteem Scale10 is a reliable and valid measure. It includes 10
items measured on a Likert-style scale ranging from 1 ⫽
strongly disagree to 4 ⫽ strongly agree. Five items are reverse coded. Higher scores indicate greater self-esteem. Cronbach alpha reliability ranges from 0.77 to 0.88.10,11 In this
sample, Cronbach alpha reliability was 0.87.
Perceived Stress Scale. The Perceived Stress Scale12 is a
reliable and valid measure. It includes 10 items measured on
a Likert-style scale ranging from 0 ⫽ never to 4 ⫽ very often.
Four items are reverse coded. Higher scores indicate greater
perceived stress. Cronbach alpha reliability ranges from 0.80
to 0.86.12 In this sample, Cronbach alpha reliability was 0.84.
Statistical Analyses
When appropriate, analysis of variance (ANOVA), the
Pearson chi-square test, or the Mann-Whitney test were used
to compare those with and without weight problems. Separate
ANOVA and analysis of covariance (ANCOVA) were conducted with the psychological dependent variables of the
Rosenberg Self-Esteem Scale and the Perceived Stress Scale.
Covariates included age, sex, race/ethnicity, hours of internet
use (daily), and number of spam e-mails received (daily).
Pearson chi-square analyses were used to compare the responses of those with and without weight problems to the
separate questions of receiving, opening, and purchasing from
spam e-mail about weight loss topics. Lastly, we conducted a
series of logistic regression analyses with three different outcome variables for receiving, opening, and purchasing from
spam e-mail about weight loss topics. For each outcome vari-
32
Table 1. Demographic characteristics of a sample of
200 individuals regarding their weight problems statusa
Variable
Age (yr)b
Sexc
Men
Women
Race/ethnicityc
White
Non-white
Hours internet use
(daily)b
No. spam e-mails
(daily)d
No weight
Yes weight
problems
problems
M (SD) or % (no.) M (SD) or % (no.)
(n ⴝ 135)
(n ⴝ 65)
20.9 (2.04)
21.0 (1.91)
40.7% (55)
59.3% (80)
24.6% (16)
75.4% (49)
42.2% (57)
57.8% (78)
3.8 (2.39)
46.2% (30)
53.8% (35)
4.2 (2.57)
P
0.69
0.03
0.60
29.7 (71.24)
25.1 (35.74)
0.13
0.39
P-values for hours of internet use are from logarithmically transformed
variables due to presence of skewness. Nonlogarithmically transformed values are shown for the mean and standard deviation values for ease of
understanding. Number of spam e-mails received, although skewed, was not
logarithmically transformed due to eight individuals with values of 0, precluding a logarithmic transformation.
a
M, mean; SD, standard deviation.
b
Analysis of variance performed.
c
Pearson ␹2 test performed.
d
Mann-Whitney test performed.
able, three models were conducted. The first model was conducted with the independent variable alone. The second model
was conducted with the independent variable and the relevant
demographic variables. The third model was conducted with
the independent variable, the relevant demographic variables,
and the psychological variables of self-esteem and perceived
stress. SPSS威 version 1513 (SPSS, Inc., Chicago, IL) was
used for all analyses, except for the calculation of Cohen’s d,
which was found using an effect size calculator.14
Results
Table 1 shows comparisons for those with (32.5%; n ⫽
65) and without (67.5%; n ⫽ 135) weight problems as pertaining to the demographic characteristics of the sample. The
average age was 21 years for both groups. There were a
significantly greater percentage of women than men with
weight problems. Slightly more than half the sample was
non-white. Each of the groups averaged four hours of daily
internet use. Although those without weight problems reported slightly more spam e-mail received daily (30 versus
25), this did not significantly differ between the groups.
Table 2 shows comparisons for weight problems and
spam e-mail behaviors. Those with weight problems were
significantly more likely than those without weight problems
to have received spam e-mail about weight loss topics, opened
spam e-mail about weight loss topics, and bought from spam
© 2010 Southern Medical Association
Original Article
Table 2. Weight problems and spam e-mail behaviors
Variable
Received weight loss e-mail
No
Yes
Opened weight loss e-mail
No
Yes
Bought from weight loss
e-mail
No
Yes
No weight
problems
% (no.)
(n ⴝ 135)
Yes weight
problems
% (no.)
(n ⴝ 65)
26.7 (36)
73.3 (99)
12.3 (8)
87.7 (57)
0.02
82.2 (111)
17.8 (24)
58.5 (38)
41.5 (27)
⬍0.001
94.8 (128)
5.2 (7)
81.5 (53)
18.5 (12)
0.003
P
e-mail about weight loss topics. Also, 18.5% [men: 3/16,
18.8%; women: 9/49, 18.4%] of those with weight problems
bought from spam e-mail about weight loss topics while only
about 5% of those without weight problems bought from
spam e-mail about weight loss topics.
With regard to comparisons for the psychological variables,
those with weight problems had lower self-esteem levels (M ⫽
29.2, SD ⫽ 6.33) than those without weight problems (M ⫽
31.4, SD ⫽ 4.88). This was significantly different with ANOVA
(P ⫽ 0.01) and also with ANCOVA (P ⫽ 0.02) when adjusting
for the covariates. There was a small-medium effect size (d ⫽
0.38). Also, those with weight problems had greater perceived
stress levels (M ⫽ 21.1, SD ⫽ 6.38) than those without weight
problems (M ⫽ 18.3, SD ⫽ 5.82). This was significantly different with ANOVA (P ⫽ 0.002) and also with ANCOVA (P ⫽
0.005) when adjusting for the covariates. There was a medium
effect size (d ⫽ 0.46).
Table 3 shows the logistic regression analyses for receiving spam e-mail about weight loss topics. In Model 1 those
with weight problems had a significant odds ratio of 2.59 as
compared to those without weight problems for receiving
spam e-mail about weight loss topics. In Model 2 that included demographics, the odds ratio for receiving spam email for those with weight problems increased to 3.24. Also,
the number of spam e-mails received was significantly associated with an increase in receiving spam e-mail about weight
loss topics. In Model 3 that included the psychological variables, both the presence of weight problems and number of
spam e-mails had similar odds ratios as in Model 2 and were
still significantly associated with an increase in receiving
weight loss spam e-mails. Also, increasing age was associated with receiving less spam e-mails about weight loss topics. None of the psychological variables were associated with
receiving weight loss spam e-mails. The Figure includes the
odds ratios for presence of weight problems for Model 3.
Southern Medical Journal • Volume 103, Number 1, January 2010
Table 3. Logistic regression analyses for receiving
weight loss spam e-maila
Variables
OR
(95% CI)
model 1
Weight problems
No
1.00
Yes
2.59 (1.13–5.96)b
Age
—
Sex
Men
—
Women
Race
White
—
Non-white
Hours internet
—
No. spam e-mails
—
Rosenberg
self-esteem
Perceived
stress
—
OR
(95% CI)
model 2
OR
(95% CI)
model 3
1.00
1.00
3.24 (1.27–8.29)b 3.39 (1.31–8.82)b
0.83 (0.69–0.99)b 0.81 (0.67–0.98)b
1.00
1.11 (0.52–2.37)
1.00
1.18 (0.55–2.54)
1.00
1.00
0.95 (0.45–1.99) 0.98 (0.47–2.06)
0.91 (0.22–3.78) 0.91 (0.22–3.78)
1.04 (1.01–1.07)c 1.04 (1.01–1.08)c
—
0.98 (0.90–1.06)
—
—
0.96 (0.89–1.04)
a
OR, odds ratio; CI, confidence interval.
P ⬍ 0.05.
c
P ⬍ 0.01.
b
Table 4 shows the logistic regression analyses for opening the spam e-mails. In all 3 models, only the presence of
weight problems was associated with significantly increased
odds for opening the e-mails. The odds ratios ranged from
3.10 to 3.29 depending upon the model (also see Fig.).
Table 5 shows the logistic regression analyses for buying
from spam e-mail about weight loss topics. In all 3 models,
the presence of weight problems was associated with significantly increased odds for buying products advertised in the
spam e-mails. For Models 1 and 2, the odds ratios were more
than 4 for doing so as compared to those without weight
problems. In Model 3, the presence of weight problems had
an odds ratio of more than 3 for buying the advertised weight
loss products. Also, increased perceived stress was associated
with buying habits (Table 3) (also see Fig.).
Discussion
We found strong support for three of our four hypotheses. Hypothesis 1 was supported where we found that the
presence of weight problems among young adults is associated with increased odds for receiving spam e-mail about
weight loss topics. Hypothesis 2 was supported where we
found that the presence of weight problems among young
adults is associated with increased odds for opening the weight
loss spam e-mails. Hypothesis 3 was supported where we
found that the presence of weight problems among young
adults is associated with increased odds for buying weight
33
Fogel and Shlivko • Spam E-mail and Weight Loss
Table 4. Logistic regression analyses for opening
weight loss spam e-maila
OR
(95% CI)
model 1
Variables
Weight problems
No
1.00
Yes
3.29 (1.70–6.37)b
Age
—
Sex
Men
—
Women
Race
White
—
Non-white
Hours Internet
—
No. spam e-mails
—
Rosenberg
—
self-esteem
Perceived stress
—
OR
(95% CI)
model 2
OR
(95% CI)
model 3
1.00
1.00
3.29 (1.65–6.56)c 3.10 (1.53–6.29)d
1.10 (0.93–1.30) 1.12 (0.94–1.33)
1.00
1.74 (0.82–3.71)
1.00
1.66 (0.77–3.56)
1.00
1.35 (0.68–2.68)
0.70 (0.19–2.58)
1.00 (0.998–1.01)
—
1.00
1.29 (0.65–2.59)
0.91 (0.19–2.68)
1.00 (0.998–1.01)
1.01 (0.94–1.09)
—
1.03 (0.96–1.11)
a
Spam e-mail on weight loss topics is quite common.
Although significantly differing between those with and without weight problems, spam e-mails about weight loss arrived
in more than 70% of the inboxes of all participants. The
opening of this spam e-mail was still somewhat of interest,
where almost 18% of those without weight problems and
more than 40% of those with weight problems opened the
spam e-mail. With regard to buying advertised products, there
4.00
Odds Ratio
3.50
3.00
No Weight Problems
Yes Weight Problems
0.50
0.00
Receiving
Opening
Buying
Fig. Spam e-mail about weight loss topics.
34
OR
(95% CI)
model 3
1.00
1.00
4.23 (1.53–11.69)b 3.38 (1.16–9.82)c
1.11 (0.87–1.41) 1.23 (0.94–1.61)
1.00
1.05 (0.36–3.09)
1.00
0.82 (0.26–2.54)
1.00
1.47 (0.54–4.02)
0.83 (0.12–5.93)
1.00 (0.99–1.01)
—
1.00
1.15 (0.40–3.29)
0.95 (0.13–7.18)
1.00 (0.99–1.01)
1.03 (0.93–1.15)
—
1.14 (1.02–1.26)c
OR, odds ratio; CI, confidence interval.
P ⬍ 0.01.
c
P ⬍ 0.05.
Prevalence of Spam E-mail on Weight Loss Topics
1.00
Weight problems
No
1.00
Yes
4.14 (1.55–11.09)b
Age
—
Sex
Men
—
Women
Race
White
—
Non-white
Hours internet
—
No. spam e-mails
—
Rosenberg
—
self-esteem
Perceived stress
—
OR
(95% CI)
model 2
b
loss products from spam e-mail. However, we only found
partial support for hypothesis 4 where increased perceived
stress is associated with buying products. However, perceived
stress was not associated with receiving or opening the spam
e-mails. Also, self-esteem was not related to receiving, opening, or buying the advertised products.
2.00
1.50
Variables
OR
(95% CI)
model 1
a
OR, odds ratio; CI, confidence interval.
P ⬍ 0.001.
c
P ⫽ 0.001.
d
P ⬍ 0.01.
b
2.50
Table 5. Logistic regression analyses for buying
products from weight loss spam e-maila
again was much more interest among those with weight problems (18.5% purchased products). There were also similar
percentages for buying among men and women. However,
only about 5% from those without weight problems bought
products. It is interesting to note that, although a very small
percentage, some individuals without weight problems bought
products from the spam e-mail. A possible reason is that,
although they do not have a “problem” with their weight,
these individuals still believe that it would be worthwhile to
lose some weight. Also, our overall buying behavior from
spam e-mail from both the weight problems and no weight
problems groups was 9.5% (19/200), which is slightly lower
than the 13% reported from a six country survey for purchasing any health or pharmaceutical products from spam e-mail.1
The National Physical Activity and Weight Loss Survey
reports the prevalence of nonprescription weight-loss supplement use within the past 12 months.15 Among its young adult
group aged 18 –34 years, the prevalence for women was
16.7% and 10.1% for men. Our buying percentage of 18.4%
for women is very similar. However, our buying percentage
of 18.8% for men is slightly higher.
Psychological Variables and Weight Concerns
As was expected for the psychological variables, we
found lower self-esteem levels and increased perceived stress
levels among those with weight problems as compared to
those without weight problems. These psychological variables are not just restricted to these particular psychological
© 2010 Southern Medical Association
Original Article
constructs. They can relate to other psychological and physical health concerns too. For example, among college students with weight problems, lower self-esteem was significantly related to a number of measures of body image
dissatisfaction.7 Also, increased stress negatively affected
those who were trying to restrain their food intake and who,
due to their stress, ate more food.16
Spam E-mail and Behavior
Those with weight problems had similar odds ratios of
greater than 3 for the models that also included the demographic and psychological variables and the 3 separate outcomes of receiving, opening, and buying from the spam emails (Fig.). A literature search did not yield any studies on
spam e-mail use and weight loss. However, there are a number of studies17–20 which show that for those seeking treatment for weight loss, counseling done through e-mail is effective in helping individuals lose weight. We suggest that
spam e-mail may appeal to those with weight problems as a
potential venue for helping them address their weight problems. This pattern of buying behavior from spam e-mail is of
concern, as these individuals are apparently not seeking or are
not satisfied with the evidence-based treatments available
from physicians, psychologists, dieticians, nurses, exercise
physiologists, or other health care providers.
Another area of concern is with regard to the content of
the weight loss products that are bought by these consumers
from this type of spam e-mail. A review of products sold by
online pharmacies indicates that pharmaceutical and herbal
products sold over the internet can range in quality from poor
to excellent.21 One concern is that spam e-mail is potentially
not any better than content sold by online pharmacies and that
the quality too can range from harmless to potentially dangerous nonprescription products. A second concern is that
some spam e-mail vendors advertise products that would require a prescription in the United States and are sold to consumers without requiring a prescription.
Our results among young adults show that an increased
number of spam e-mails received is associated with receiving
spam e-mail about weight loss topics, while the number of
hours of internet use is not associated with receiving spam
e-mail about weight loss topics. This is similar to the significant association between the number of spam e-mails received and the health spam e-mail received and to the lack of
a relationship for hours of internet use and health spam e-mail
received among college-age and working-age individuals.3
In the analyses for opening spam e-mail about weight
loss topics, no demographic or psychological variables were
associated with opening these e-mails. However, increased
perceived stress was associated with increased odds for buying from the spam e-mails. Apparently, just as consumers
shop for consumer goods as a form of stress relief,22 stress
relief may be an additional reason for purchasing weight loss
products from spam.
Southern Medical Journal • Volume 103, Number 1, January 2010
Physician Implications
The American Medical Association strongly encourages
physicians to assess weight and to discuss with patients the
health implications of being overweight or obese.23 Patients
will not typically initiate a discussion with their physician
about weight concerns. Even when patients are already purchasing nonprescription weight-loss supplements, less than
one-third of young adults discuss these supplements with a
physician or other health care professional.15 It is also not so
simple to effectively counsel patients to lose weight. One
approach found effective by many primary care physicians is
to focus on improving a patient’s general health habits and
wellness instead of focusing on a particular weight.24 Along
with assessing and possibly counseling and/or treating patients for weight topics, it would be worthwhile to inquire
about weight loss supplement use and also the source of the
supplements.
Study Limitations and Future Research
The study has some potential limitations. First, these data
were collected at one university and may not be representative of a national sample. Second, it may have been informative to obtain the body mass index of the participants to
determine if being overweight was related to this buying
behavior. However, weight perception is often quite subjective and many individuals who have appropriate weight will
still seek to lose just a few pounds, so objective overweight
status is not critical to understanding this spam e-mail buying
behavior. Third, as this is the first such study, future research
would be useful to conduct similar research to replicate these
study findings with a larger sample size in a national sample.
Fourth, it would be useful in future research to understand the
actual products purchased from spam e-mail (ie herbal products, prescription medication, etc) to determine the actual
potential risk from using such products. Fifth, future studies
should also assess whether there are adverse events from the
weight loss products purchased online.
Conclusion
Spam e-mails about weight loss are being looked at and
purchased from, especially among those who are sensitive to
weight concerns. Clearly, those who are sending these spam
marketing e-mails have a receptive audience. Physicians, psychologists, dieticians, nurses, exercise physiologists, or other
health care providers who assess, counsel, and treat individuals for weight concerns should discuss with their patients the
potential risks of opening and/or purchasing from spam email. They should emphasize to their patients the importance
of working together with a health care professional in coordinating care when considering the use of weight loss products. It may even be useful for physicians to ask all their
patients if they are purchasing health products from spam
e-mail. Future research should study if health care profes-
35
Fogel and Shlivko • Spam E-mail and Weight Loss
sionals’ discussions with patients who purchase from spam
e-mail results in changed purchasing behavior from spam
e-mail among these patients.
12. Cohen S, Williamson G. Perceived Stress in a Probability Sample of the
United States, in Spacapan S, Oskamp S (eds): The Social Psychology of
Health: Claremont Symposium on Applied Social Psychology. Newbury
Park, CA, Sage, 1988, pp 31– 67.
References
13. SPSS Version 15. Chicago, SPSS, 2006.
1. Forrester Research, Business Source Alliance. Consumer Attitudes Toward Spam in Six Countries. 2004. Available at: http://www.bsa.org/
country/Research%20and%20Statistics/⬃/media/87F4037F2B70
44ECBF448A227B84BE86.ashx. Accessed January 21, 2009.
2. Fallows D. Spam 2007. Available at: http://www.pewinternet.org/pdfs/
PIP_Spam_May_2007.pdf. Accessed July 12, 2007.
3. Grimes GA, Hough MG, Signorella ML. Email end users and spam:
relations of gender and age group to attitudes and actions. Comput
Human Behav 2007;23:318 –332.
4. Mailshell. Results of the SpamCatcher Attitude Survey. 2003. Available
at: http://www.mailshell.com/mail/client/oem2.html/step/pr/article/17.
Accessed June 02, 2007.
5. Marshal. Sex, Drugs and Software Lead Spam Purchase Growth. 2008.
Available at: http://www.marshal.com/pages/newsitem.asp?article⫽
748&thesection⫽news. Accessed January 21, 2009.
6. Gernburd P, Jadad AR. Will spam overwhelm our defenses? Evaluating
offerings for drugs and natural health products. PLoS Med 2007;4:e274.
14. Becker. Effect Size Calculators. 2005. Available at: http://web.uccs.edu/
lbecker/Psy590/escalc3.htm. Accessed August 9, 2007.
15. Blanck HM, Serdula MK, Gillespie C, et al. Use of nonprescription
dietary supplements for weight loss is common among Americans. J Am
Diet Assoc 2007;107:441– 447.
16. Wardle J, Steptoe A, Oliver G, et al. Stress, dietary restraint and food
intake. J Psychosom Res 2000;48:195–202.
17. Harvey-Berino J, Pintauro S, Buzzell P, et al. Effect of internet support
on the long-term maintenance of weight loss. Obes Res 2004;12:320 –
329.
18. Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized
trial. JAMA 2003;289:1833–1836.
19. Tate DF, Jackvony EH, Wing RR. A randomized trial comparing human
e-mail counseling, computer-automated tailored counseling, and no
counseling in an Internet weight loss program. Arch Intern Med 2006;
166:1620 –1625.
7. Lowery SE, Robinson Kurpius SE, Befort C, et al. Body image, selfesteem, and health-related behaviors among male and female first year
college students. J Coll Stud Dev 2005;46:612– 623.
20. Tate DF, Wing RR, Winett RA. Using internet technology to deliver a
behavioral weight loss program. JAMA 2001;285:1172–1177.
8. Metz U, Welke J, Esch T, et al. Perception of stress and quality of life
in overweight and obese people—implications for preventive consultancies in primary care. Med Sci Monit 2009;15:PH1–PH6.
21. Fogel J. Consumers and Purchases of Health Products Over the Internet,
in Saito F (ed): Consumer Behavior. Hauppauge, NY, Nova Science,
2009, pp 105–115.
9. Nishitani N, Sakakibara H. Relationship of obesity to job stress and
eating behavior in male Japanese workers. Int J Obes 2006;30:528 –533.
22. Hama Y. Shopping as a coping behavior for stress. Jpn Psychol Res
2001;43:218 –224.
10. Rosenberg M. Conceiving the Self. Malabar, FL, Krieger, 1986.
11. Blascovich J, Tomaka J. Measures of Self-Esteem, in Robinson JP,
Shaver PR, Wrightsman LS (eds): Measures of Personality and Social
Psychological Attitudes. Ann Arbor, Institute for Social Research, 1993,
ed 3, pp 115–160.
36
23. Lyznicki JM, Young DC, Riggs JA, et al. Obesity: assessment and
management in primary care. Am Fam Physician 2001;63:2185–2196.
24. Sussman AL, Williams RL, Leverence R, et al. The art and complexity
of primary care clinicians? Preventive counseling decisions: obesity as a
case study. Ann Fam Med 2006;4:327–333.
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