Commercial weight management solutions – what can you advise your patients?

Robert HobsonPublic Health Nutritionist

Overweight and obese - Current situation

61% UK overweight24% UK obese Complex disease with many influencing

factorsForesight report – 100 variables which

directly or indirectly effect energy balanceAround 6000 dietitians in the UK to help treat

the diseaseNHS Limited resourcesObesity – issues too great for any one

organisation

Overweight and obese - Current management

Primary Care Trust’s and voluntary organisationsWeight management groupsDrop-in clinicsCookery clubsExercise clubsBMI 30+ free vouchers for weight watchers

Barriers to successFunding/who commissions?Lack of resourcesCompliance/motivation Lack of innovation/support

Commercial slimming groups

Policy documents recommending partnership between Commercial slimming groups and NHS

Choosing Health1

Healthy Weight : Healthy Lives2

GP referral schemes existSlimming World Weight Watchers

Many LA and primary care organisations already commissioning groups

Heath and Social Care Bill 2011 – who commissions in future

NICE guidance CG43

National institute for Health and Clinical excellence (NICE) guidance CG433

Guidance on prevention, Identification, Assessment and management of overweight and obese Adults and children

Suggests that primary care organisations and LA recommend commercial weight management programmes which met the standards of best practice

NICE guidance CG43 – standards of best practice

Help people assess their weight and decide on a realistic healthy target weight - usually a weight loss of 5-10% of the original weight

Aim for a maximum weekly weight loss of 0.5-1kg

Focus on long term lifestyle changes rather than a short term, quick fix approach

Be multi-component, addressing both diet and activity while offering a variety of approaches

NICE guidance CG43 – standards of best practice

Use a balanced healthy eating approachRecommend regular physical activity,

ideally daily activities like walking and gardening, and offer advice about increasing activity safely

Include behaviour change techniques, such as keeping food diaries, dealing with lapses and high risk situations

Recommend or provide ongoing support

Commercial weight management programmes

What’s out there?

Weight WatchersSlimming WorldJenny CraigLighter Life

How do these weight management programmes work?

How effective are they?

Weight watchers

Founded in USA, 1963Over 1 million members worldwide 50,000 meeting groupsCombines diet and physical activity advice with

behaviour change techniquesRegular support group meetingsMembership free if weight goals met -

incentiveNICE compliant

Weight watchers

Eating plan based on a point system‘ProPoints system’ assigns each food with a

point and takes into account satiety Points are allocated based on gender, weight,

height and activity levelPoints allocated to achieve 0.5 – 1 kg per

weekWeight loss target is 10% of original weightMember chooses balance of foods – emphasis

on healthy eating and satiety (lean proteins and whole grains)

Weight watchers

Group support – weekly meetings (critical to success)Group leaders are previous membersGroups leaders manage points as weight is lostInteractive online membership available Weight watchers online – support and information Member forumsInteractive activity demonstrationsMagazine1000’s of own brand food products – points system

Slimming World

Founded in UK, 19697500 weekly meetingsProgram combines healthy diet and physical

activity advice with support and long-term behaviour change

IMAGE therapy (Slimming World technique)Regular support group meetingsMembers set own realistic targetsMembership free if target weight met - incentiveNICE compliant

Slimming World‘Food optimising plan’Promotes low energy dense foods and

controls high energy dense foodsUnlimited ‘free foods’ – starchy carbs, lean

protein, fruit and veg, low fat yoghurtsAllocated portions of ‘healthy extras’ –

wholegrain cereals, breads, milk, cheese and dried fruit/nuts

Daily allowance (optional) of ‘syns’ – confectionary, savoury snacks and alcohol

Help members learn – no food banned in healthy lifestyle

Slimming World

Weight loss target is around 10% of original weightWeight loss target chosen by memberWeight loss goal of 0.5 – 1kg per weekGroups support - weekly meetings (critical to

success)Group leaders – previous membersExchange IMAGE info, recipes, motivation and

support from leader/membersInteractive website – information and support Magazine, recipe books and email/telephone support

Jenny Craig

Founded in Australia, 1983Recently introduced to UK after success overseasHolistic ‘food-mind-body’ approachMembers purchased ambient branded food

productsHome deliveredProgram combines personally designed eating

plans, physical activity advice, telephone support and behaviour change strategies

Vitamin and mineral supplementation recommended

NICE compliant

Jenny Craig

Portion controlled and focus on low energy density

Menu plans offer 1200 – 2300 kcal dailyAs well as purchased food members

encourage to consume fruit and veg and low fat dairy products

Members learn about portion size through food packs

Re-introduction to home cooked meals when halfway to goal weight

Jenny CraigMember assigned personal weight management

coachTarget weight loss agreed between member and

coach (0.5-1kg weight loss per week)Private, weekly telephone consultation

EncouragementSupport strategies – eating out, holidaysAdjust eating plansDesign weekly activity plan

Health cooking support via councilor and recipe booklets

Lighter Life Founded in UK, 1996Two eating plans:

Very low calorie diet (VLCD)- BMI > 30

Low calorie diet (LCD)- BMI between 25-29.9

Meal replacement powdersSingle sex group meetings, weekly weigh-in,

behaviour change support and physical activity advice

Heavily regulated – COMA, SCOOP, CODEX, NICE

Lighter Life

VLCD – 500-600kcals per day, 12 weeksGP referral, contraindicated medical

conditions, 28 day check up (COMA, NICE)Solely meal replacement powdersDietary ketosisRapid weight loss at startPowders gradually replaced by normal food

during ‘phase one management stage’Normal food based on low energy densityDiogenes – foodplate – low GI www.diogenes-eu.org

Lighter Life

LCD – 800-1200 kcal per day3 food packs (replacement powders) and

one healthy meal (recipes provided)Rapid weight lossPowders replaced by normal food during

the ‘phase one management stage’ Normal food based on low energy densityDiogenes - foodplate

Lighter Life

Weekly group meeting (critical to success)Group leaders mostly past membersGroup leaders have an accredited BTEC

certificate or diploma in weight-management consultancy

Strong emphasis of CBT therapy during meetings as well as support from other members

Membership free if target weight met – incentive

Magazine/cookbooks/recipe booksOnline forum and podcasts

Evidence of efficacy

Majority of research carried out by Weight Watchers, Slimming World and Lighter Life

Research shows that in general commercial weight management programmes work

As with any weight loss therapy long-term weight loss is pretty modest – No panacea

Compliance with a programme is key to it’s success

More research on improving compliance would be very useful

Jolly et al (2011)4

Randomized control trialAssess effectiveness of weight management

programmes (WW, RC, SW, NHS)Comparator group received free vouchers to

leisure centre740 overweight and obese individuals from UKCommercial programmes achieved significantly

greater weight loss than the primary care programmes

At progammes’ end, mean difference of 2.3 kgPrimary care programmes more costly

Jebb et al (2011)5

Randomized control trial (12 months)Compared referral to commercial weight loss

treatment (Weight Watchers) with standard care722 overweight and obese individuals from UK,

Germany and AustraliaThose assigned to the commercial weight

programme lost twice as much weight compared with standard care at 12 months (5.06kg and 2.25kg respectively)

Three times more likely to lose 10% of initial weight on commercial weight management programme

Useful early intervention for weight management in overweight and obese people

Can be delivered on a large scale

Truby et al (2006)6

Randomized control trial (6 months, multicentre)Compared effectiveness of 4 commercial weight loss

diets (including weight watchers and Rosemary Connelly)

All produced statistically significant weight loss Intention to treat analysis showed average weight

loss of 5.9kg and fat loss of 4.4kgMinimal difference between the groups but greater

weight and fat loss than control group Useful weight and fat loss in individuals motivated

to follow commercial weight loss diet

Heshka et al (2003)6

Randomized control trial (24 months)Compared standard self-help weight loss (2 sessions

with nutritionist) with commercial weight management programme (Weight Watchers)

423 overweight and obese individuals25% attrition (often not reported in studies)Intention-to -treat analysis showed average weight

loss of 2.9kg after 2 yrs in the commercial group compared with 0.2kg in the self-help group

Modest weight loss in the commercial group but more than that of the self-help group

Bariatric surgery

What is it?When is it an appropriate solution?NICE CG43 guidanceHow easy to access privately e.g. overseasEvidence of efficacy

Bariatric surgery – what is it?

Generic term for weight loss surgeryMore effective in achieving weight loss

that non-surgical treatment – longer termNHS commissioned procedures increased

from 470 in 2003/04 to 6500 in 2009/10Equivalent to <1% of morbidly obese in

UK

Bariatric surgery – what is it?

Most common procedures:

Adjustable gastric bandingGastric bypass

Associated risksRequires extensive follow upWaiting list high – lack of funding from PCT

Bariatric surgery – when is it appropriate?

NICE guidance CG43BMI ≥ 40 or between BMI 35 and BMI 40

with other significant disease which could be improved

Tried all non-surgical treatments – failed weight loss at 6 months

Receiving intense management in a specialist obesity service

Fit for surgery – anesthesiaCommitment to long term follow upFirst-line option BMI ≥ 50

Bariatric surgery – Overseas treatment – risk?

In the press over the yearsEurope and IndiaCosmetic treatment – BMI<25Increase risk – would you travel back to

countryOften no follow up or proper aftercareDiet, supplementation, gastric band

adjustmentsNHS left to ‘pick up the pieces’

Bariatric surgery – how effective?

Two systematic reviewsEffectiveness in relation to obesity Picot J, Jones J, Colquitt J, et al (2009)7

Colquitt J, Picot J, Loveman E, et al (2009)8

Both involved 26 studies3 RCT’s, 3 Cohorts compared surgery vs

non-surgery20 RCT’s compared surgical treatments

Bariatric surgery – how effective?

Key findings

More effective weight loss and long term weight maintenance in people BMI>30

Improve co-morbidities – diabetes and hypertension

Improvements in health related quality of lifeNo clear evidence that one type of surgery leads to

more weight loss or improvement in co-morbiditiesSurgery more costly that non-surgical but gave

improved outcomes

Hallam et al (2010) – not published Retrospective study (8 months)Determine if morbidly obese patient (BMI ≥ 50)

could comply with VLCD (Lighter Life)650 obese individuals, compliance tested using

urinary ketone reagent strips (test ketosis)88.5% participation at 4 weeks, 80.2%

participation at 8 weeks and 66.5% participation at 12 weeks

Average weight loss at 12 weeks 3 stone 10lbSimilar results, low morbidity and lower costsWeekly group meetings – CBT therapy, Healthy

lifestyleVLCD – viable replacement to surgical

management of obesity?Depends on patient

Do different programs suit different people?

Lot’s of choice – all offering slightly different methods of weight management

Useful to have NICE CG43 guidance to establish which programmes are suitable in the treatment of overweight and obesity

List of preferred providers – NICE compliant, descriptions/check list?

One size does not fit all – key to successful weight management is keeping positive changes, activity and behaviour going

Do different programs suit different people?

Discuss patient lifestyle, time commitments, work schedule, family set-up and previous attempts at weight loss

Identify client need to change for goodGroups motivation? One-to-one support?

Convenience? Access to resourcesKnowledge of programmes can help to

match client needs First step to a more permanent weight

management success

References1. DOH (2004). Choosing health : making healthier choices

easier. London. Department of Health2. COI (2008). Healthy weight, healthy lives: a cross

government strategy for England. London. Department of Health.

3. NICE (2006) Obesity: The Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children. London: NICE

4. Kate Jolly, Amanda Lewis, Jane Beach, John Denley, Peymane Adab, Jonathan J Deeks, Amanda Daley, Paul Aveyard (2011). Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: Lighten Up randomised controlled trial. BMJ 343:d6500

5. Jebb SA, Ahern AL, Olson AD, Aston LM, Holzapfel C, et al (2011). Primary care referral to a commercial provider for weight loss treatment versus standard care: an international randomised controlled trial. Lancet;378:1485-92.

References6. Helen Truby, Sue Baic, Anne deLooy, Kenneth R Fox, M Barbara

E Livingstone, Catherine M Logan, Ian A Macdonald, Linda M Morgan, Moira A Taylor, D Joe Millward (2006). Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC “diet trials”. BMJ 332:1309

7. Heshka S, Anderson JW, Atkinson RL (2003). Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA; 289:1792-8

8. Colquitt JL, Picot J, Loveman E, et al. Surgery for obesity. Cochrane Database of Systematic Reviews, Issue 2.

9. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess, 13(41).