**3. Self-monitoring and new technologies**

Self-monitoring is described as a "Cornerstone" of behavioral weight control intervention [18] and one of the most important and effective techniques developed in the area of behavioral therapy applied to obesity's treatment [18, 19]. The processes involved are selfobservation, self-evaluation, and self-reinforcement. Self-regulation involves establishing goals, expectations and plans, monitoring the subject's behaviors, and evaluating performances [19]. A person can change his dysfunctional behavior by becoming aware of it [20]. Self-monitoring is positively correlated with self-awareness, playing a crucial role in the eating behaviors. Consistency of self-monitoring is often associated with weight control [21, 22]. Self-monitoring's consistency can help patients managing weight control. Consistency of self-monitoring reflects the frequency, completeness, and quality of self-monitoring. By improving consistency of self-monitoring, patients can learn control their behavior in a better way. Improvements of self-monitoring are associated with a decrease of weight. In addition, self-monitoring seems to impact on self-evaluation and self-regulation of weight. Baker and Kirschenbaum [23] highlighted how high levels of self-monitoring may be helpful for a more significant weight loss. In order to improve self-monitoring, it is necessary to clearly understand the normative levels, monitoring behavior, and therapist and client expectations, regarding the consistency of self-monitoring. The authors consider self-monitoring both as a state and a trait: some people tend to monitor themselves very consistently, whereas other people tend to do it very inconsistently. Furthermore, while some people, under some conditions monitor themselves consistently, others may reduce levels of self-monitoring if they are sick or emotionally distraught. In obesity treatment, self-monitoring plays a crucial role, as demonstrated by Baker and Kirschenbaum [23]. The aim of Baker's study was to know whether specific variables were more linked to weight control than others. The results show that control over any food eaten, all foods eaten, time when food was eaten, quantity of food eaten, and the percentage of fat eaten are directly linked to higher levels of weight control. On the other hand, control of other specific variables, such as water intake, was unrelated to weight control. This study suggests that when subjects self-monitor any food, they tend to control other variables for the whole day. This result confirms that self-monitoring follows the principles of: "all or none." The type of self-control needed in order to prevent failure is defined by Kirschenbaum et al. [22] as "obsessive-compulsive self-regulation." Traditional behavioral weight control programs can be very expensive and require lot of time for participants [24]. Furthermore, these interventions are not always available for everyone [18]. Technology-based behavioral interventions, called "eHealth" interventions, have been developed to address barriers associated with traditional treatment. These interventions use new technologies, such as smartphone applications (apps), websites, and/or online social media networks, to deliver behavioral weight loss treatment. Nowadays, digital health represents a key dimension of healthcare [25]. These new technologies include websites, smartphone applications (apps), and smart scales allowing individuals to view and monitor their weight, caloric intake, and physical activity [26]. New technologies ensure a lot of advantages on treatment, allowing individuals setting own goals, comparing their self-monitoring data, and reinforcing the process of reaching short- and long-term goals. Ross and Wing [26] designed a study that aimed to investigate the impact of newer self-monitoring technology (compared to traditional self-monitoring tools), provided with and without a brief phone-based intervention, on weight loss in adults with overweight and obesity. As supposed by the authors, findings suggest that newer self-monitoring technology combined with a brief phone-based intervention can improve adherence to self-monitoring and lead to greater weight losses than traditional interventions. Patients who join internet-based programs show greater levels of adherence to self-monitoring than participants of traditional treatments [20]. A study conducted by Krukowski et al. [27] shows that participants who consistently self-monitor during program are more likely to achieve better results in weight loss within 6 months than others. It appears important to continue self-monitoring throughout a 6-month weight loss program. Online self-monitoring appears to be strongly associated with weight loss outcomes. Over many years, review and meta-analysis have highlighted the available evidence for eHealth interventions for weight management [6]; Burke [20] conducted a study in which they compared the use of a personal digital assistant with dietary and exercise software, with and without a feedback message, and a paper diary/record, in order to determine which type of treatment results in greater weight loss and improved self-monitoring adherence. The results showed that all participants had a significant weight loss, but those who received a personal digital assistant with a feedback message lost more than 5% weight compared to other groups. Internet-based weight loss and maintenance programs have shown a small effect in moderating weight loss in obese patients, because of the heterogeneity of the intervention components [28]. Despite efforts to improve outcomes from web-based weight control and maintenance interventions, researches found that weight losses tend to be smaller than 7–10% weight losses obtained in traditional interventions [18]. The small effect obtained has been improved by providing interactivity and other basic characteristics of traditional interventions such as self-monitoring of caloric intake, physical activity, and regular feedback on goal achievement [29]. Other findings suggest that a frequent use of web-based intervention materials has been linked to better weight loss results [28, 30]. Mobile technologies for weight management often include apps, text messaging, wearable sensors, and social media interventions. Personal digital assistants (PDAs) and other smartphone apps promote adherence, self-monitoring, and goal achievement. Users can also contact their remote coach or other participants [31]. This type of interventions appears to be more effective than traditional programs [32]. On the other hand, several studies have not found positive effects of apps over other interventions [31]. Feedback on goal achievement progress or self-monitoring is provided through text messages [33]. Evidences support the effectiveness of text messaging on treatments for weight loss [34]. Adherence to text messaging represents a predictor for weight loss; in other words, if participants respond to text prompts, they tend to lose more weight than others [34]. Social media are a useful device for connecting people taking part in treatments. Social support acts as an important facilitator in the achievement of health behavior change and goals [35]. Recent studies demonstrate the effectiveness of media support to encourage weight loss. For example, Napolitano and colleagues [33] show that participants who interacted with each other throughout Facebook and received intervention material and messages supporting weight loss lost more weight than participants from other control groups. This new line of research requires additional evidences, although it is still too soon to evaluate the efficacy of this new

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type of interventions [35].

a study that aimed to investigate the impact of newer self-monitoring technology (compared to traditional self-monitoring tools), provided with and without a brief phone-based intervention, on weight loss in adults with overweight and obesity. As supposed by the authors, findings suggest that newer self-monitoring technology combined with a brief phone-based intervention can improve adherence to self-monitoring and lead to greater weight losses than traditional interventions. Patients who join internet-based programs show greater levels of adherence to self-monitoring than participants of traditional treatments [20]. A study conducted by Krukowski et al. [27] shows that participants who consistently self-monitor during program are more likely to achieve better results in weight loss within 6 months than others. It appears important to continue self-monitoring throughout a 6-month weight loss program. Online self-monitoring appears to be strongly associated with weight loss outcomes. Over many years, review and meta-analysis have highlighted the available evidence for eHealth interventions for weight management [6]; Burke [20] conducted a study in which they compared the use of a personal digital assistant with dietary and exercise software, with and without a feedback message, and a paper diary/record, in order to determine which type of treatment results in greater weight loss and improved self-monitoring adherence. The results showed that all participants had a significant weight loss, but those who received a personal digital assistant with a feedback message lost more than 5% weight compared to other groups. Internet-based weight loss and maintenance programs have shown a small effect in moderating weight loss in obese patients, because of the heterogeneity of the intervention components [28]. Despite efforts to improve outcomes from web-based weight control and maintenance interventions, researches found that weight losses tend to be smaller than 7–10% weight losses obtained in traditional interventions [18]. The small effect obtained has been improved by providing interactivity and other basic characteristics of traditional interventions such as self-monitoring of caloric intake, physical activity, and regular feedback on goal achievement [29]. Other findings suggest that a frequent use of web-based intervention materials has been linked to better weight loss results [28, 30]. Mobile technologies for weight management often include apps, text messaging, wearable sensors, and social media interventions. Personal digital assistants (PDAs) and other smartphone apps promote adherence, self-monitoring, and goal achievement. Users can also contact their remote coach or other participants [31]. This type of interventions appears to be more effective than traditional programs [32]. On the other hand, several studies have not found positive effects of apps over other interventions [31]. Feedback on goal achievement progress or self-monitoring is provided through text messages [33]. Evidences support the effectiveness of text messaging on treatments for weight loss [34]. Adherence to text messaging represents a predictor for weight loss; in other words, if participants respond to text prompts, they tend to lose more weight than others [34]. Social media are a useful device for connecting people taking part in treatments. Social support acts as an important facilitator in the achievement of health behavior change and goals [35]. Recent studies demonstrate the effectiveness of media support to encourage weight loss. For example, Napolitano and colleagues [33] show that participants who interacted with each other throughout Facebook and received intervention material and messages supporting weight loss lost more weight than participants from other control groups. This new line of research requires additional evidences, although it is still too soon to evaluate the efficacy of this new type of interventions [35].

**3. Self-monitoring and new technologies**

154 Cognitive Behavioral Therapy and Clinical Applications

Self-monitoring is described as a "Cornerstone" of behavioral weight control intervention [18] and one of the most important and effective techniques developed in the area of behavioral therapy applied to obesity's treatment [18, 19]. The processes involved are selfobservation, self-evaluation, and self-reinforcement. Self-regulation involves establishing goals, expectations and plans, monitoring the subject's behaviors, and evaluating performances [19]. A person can change his dysfunctional behavior by becoming aware of it [20]. Self-monitoring is positively correlated with self-awareness, playing a crucial role in the eating behaviors. Consistency of self-monitoring is often associated with weight control [21, 22]. Self-monitoring's consistency can help patients managing weight control. Consistency of self-monitoring reflects the frequency, completeness, and quality of self-monitoring. By improving consistency of self-monitoring, patients can learn control their behavior in a better way. Improvements of self-monitoring are associated with a decrease of weight. In addition, self-monitoring seems to impact on self-evaluation and self-regulation of weight. Baker and Kirschenbaum [23] highlighted how high levels of self-monitoring may be helpful for a more significant weight loss. In order to improve self-monitoring, it is necessary to clearly understand the normative levels, monitoring behavior, and therapist and client expectations, regarding the consistency of self-monitoring. The authors consider self-monitoring both as a state and a trait: some people tend to monitor themselves very consistently, whereas other people tend to do it very inconsistently. Furthermore, while some people, under some conditions monitor themselves consistently, others may reduce levels of self-monitoring if they are sick or emotionally distraught. In obesity treatment, self-monitoring plays a crucial role, as demonstrated by Baker and Kirschenbaum [23]. The aim of Baker's study was to know whether specific variables were more linked to weight control than others. The results show that control over any food eaten, all foods eaten, time when food was eaten, quantity of food eaten, and the percentage of fat eaten are directly linked to higher levels of weight control. On the other hand, control of other specific variables, such as water intake, was unrelated to weight control. This study suggests that when subjects self-monitor any food, they tend to control other variables for the whole day. This result confirms that self-monitoring follows the principles of: "all or none." The type of self-control needed in order to prevent failure is defined by Kirschenbaum et al. [22] as "obsessive-compulsive self-regulation." Traditional behavioral weight control programs can be very expensive and require lot of time for participants [24]. Furthermore, these interventions are not always available for everyone [18]. Technology-based behavioral interventions, called "eHealth" interventions, have been developed to address barriers associated with traditional treatment. These interventions use new technologies, such as smartphone applications (apps), websites, and/or online social media networks, to deliver behavioral weight loss treatment. Nowadays, digital health represents a key dimension of healthcare [25]. These new technologies include websites, smartphone applications (apps), and smart scales allowing individuals to view and monitor their weight, caloric intake, and physical activity [26]. New technologies ensure a lot of advantages on treatment, allowing individuals setting own goals, comparing their self-monitoring data, and reinforcing the process of reaching short- and long-term goals. Ross and Wing [26] designed
