Weight management programmes of extended duration
Authors: Emily Brindal
Journal: The Lancet (2017)

In 2014, 52% of adults globally were overweight or obese.1WHOFiscal policies for diet and prevention of non-communicable diseases. Technical Meeting Report (5–6 May 2015). World Health Organization Document Production Services, Geneva2016Google Scholar Lifestyle programmes, which target improved diet and exercise practices, reliably produce clinically relevant weight changes and are viable options that can reach multiple populations and be delivered on a large scale. Consequently, these lifestyle programmes remain a popular approach to weight management despite better long-term weight loss outcomes being observed using different methods.2Anderson JW Konz EC Freerich RC et al.Long-term weight-loss maintenance: a meta-analysis of US studies.Am J Clin Nutr. 2001; 74: 79-84Google Scholar, 3Douketis JD Macie C Thabane L et al.Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice.Int J Obes. 2005; 29: 1153-1167Crossref PubMed Scopus (451) Google Scholar Amy Ahern and colleagues4Ahern AL Wheeler GM Aveyard P et al.Extended and standard duration weight loss referrals for adults in primary care (WRAP): a pragmatic randomised controlled trial.Lancet. 2017; (published online May 3)http://dx.doi.org/10.1016/S0140-6736(17)30647-5PubMed Google Scholar empirically assessed the effects of extended access to a group-based, commercial weight loss programme (Weight Watchers). Their large, randomised controlled trial (n=1267 patients) compared the effects on weight loss (alongside other clinical outcomes) of a brief intervention with 12-week and 52-week programme referrals (free access). The investigators used primary care providers to recruit adults who were overweight or obese across England. Both referral groups referred to the commercial programme showed better weight loss outcomes than the brief intervention group, which received only self-help materials from their doctor. Mean weight loss in participants given a 52-week referral was 6·76 kg at 12 months and 4·29 kg at 24 months, which represented 2·14 kg and 1·32 kg greater weight loss compared with the 12-week referral group at these same timepoints (when adjusted for baseline values and centre). Although modest, these differences are relevant within the pragmatic objectives of the study—ie, to understand whether extended access to a weight management programme could improve weight loss in a real-world setting. Furthermore, the accompanying economic analysis dispels cost-prohibitive arguments about extended programme access and greatly strengthens the proposal that 52-week referrals to a commercial programme might be a worthwhile alternative to the 12-week referrals currently supported by the National Health Service (NHS) in the UK. The finding that prolonged access to interventions can improve weight outcomes might seem obvious at first; if participants have extended access to active support, they continue to lose weight. However, sparse empirical studies have attempted to quantify the effects of active intervention duration on weight loss outcomes. The widely used 12-week duration for academic study of weight loss programmes and in commercial offerings has no clear clinical basis and it is a challenge to find substantiating empirical studies. Some studies have explored specific aspects of interventions, such as frequency and style of participant contact,5Svetkey LP Stevens VJ Brantley PJ et al.Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial.JAMA. 2008; 299: 1139-1148Crossref PubMed Scopus (576) Google Scholar which might overlap with intervention duration. Few studies, if any, have sought to directly test the effects of different intervention durations. The comparison of different intervention lengths creates some methodological challenges. For example, data collected at follow-up visits represent different lengths of inactive intervention within each participant group. Despite some criticism,6Patsopoulos NA A pragmatic view on pragmatic trials.Dialog Clin Neurosci. 2011; 13: 217-224Crossref PubMed Google Scholar pragmatic trials are an excellent method for overcoming such challenges and informing current practice. Beyond this applied focus, the results presented by Ahern and colleagues4Ahern AL Wheeler GM Aveyard P et al.Extended and standard duration weight loss referrals for adults in primary care (WRAP): a pragmatic randomised controlled trial.Lancet. 2017; (published online May 3)http://dx.doi.org/10.1016/S0140-6736(17)30647-5PubMed Google Scholar suggest that prolonged access to active intervention might offer a simple and cost-effective method for improving weight loss outcomes in lifestyle intervention programmes. This is an important finding because higher initial weight loss can improve long-term success of weight management.7Astrup A Rossner S Lessons from obesity management programmes: greater initial weight loss improves long-term maintenance.Obesity Rev. 2000; 1: 17-19Crossref PubMed Scopus (153) Google Scholar Prolonged active intervention could increase weight loss simply by delaying the onset of weight regain, which is considered stable and unrelated to initial weight loss or programme characteristics.8Hartmann-Boyce J Aveyard P Onakpoya I et al.Weight regain after behavioural weight management programmes. University of Oxford, Oxford2013https://www.nice.org.uk/guidance/ph53/evidence/evidence-review-1c-431707935Google Scholar However, could extended treatment duration be used to mitigate the substantial challenge of weight regain? Weight monitoring, accountability, and different types of support are crucial aspects for both weight loss and weight-maintenance interventions5Svetkey LP Stevens VJ Brantley PJ et al.Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial.JAMA. 2008; 299: 1139-1148Crossref PubMed Scopus (576) Google Scholar, 9National Institute of Health and Clinical ExcellenceManaging overweight and obesity in adults—lifestyle weight management services (NICE Guidance).https://www.nice.org.uk/guidance/ph53/resources/weight-management-lifestyle-services-for-overweight-or-obese-adults-1996416726469Date: 2014Google Scholar, 10Wing RR Hill JO Successful weight loss maintenance.Ann Rev Nutr. 2001; 21: 323-341Crossref PubMed Scopus (1032) Google Scholar and these could be pragmatically provided through existing lifestyle programmes. For this to result in successful weight maintenance, the length of access to treatment might need to extend to 2–5 years.10Wing RR Hill JO Successful weight loss maintenance.Ann Rev Nutr. 2001; 21: 323-341Crossref PubMed Scopus (1032) Google Scholar This success would also require a paradigm shift away from the current mindset of separating active intervention and weight regain prevention towards weight management as a single, dynamic, and ongoing process. Extending intervention duration inevitably leads to consideration of participant engagement. How long can participant interest and motivation be maintained? Despite greater weight loss, 29% of participants in the 52-week referral group reported regular attendance at group sessions in the 12 weeks preceding week 52.4Ahern AL Wheeler GM Aveyard P et al.Extended and standard duration weight loss referrals for adults in primary care (WRAP): a pragmatic randomised controlled trial.Lancet. 2017; (published online May 3)http://dx.doi.org/10.1016/S0140-6736(17)30647-5PubMed Google Scholar In a separate study assessing the Weight Watchers programme, a similar level of engagement was achieved in approximately 23% of participants over 24 months.11Heshka S Anderson JW Atkinson RL et al.Weight loss with self-help compared with a structured commercial program: a randomized trial.JAMA. 2003; 289: 1792-1798Crossref PubMed Scopus (366) Google Scholar In the absence of any referral or free access, participants in the Pound of Prevention study12French SA Jeffery RW Murray D Is dieting good for you? Prevalence, duration and associated weight and behaviour changes for specific weight loss strategies over four years in US adults.Int J Obesity. 1999; 23: 320-327Crossref PubMed Scopus (116) Google Scholar had a median duration of 2 weeks' attendance at group weight management programmes over a 4-year period. Thus, referral or free access might extend participant engagement, but close to three quarters of participants appear to be failing to engage in the programme after 12–24 months. Intervention engagement is likely to vary according to participant starting weights, motivation, and goals, as well as programme characteristics. Improving engagement could result in better weight loss outcomes11Heshka S Anderson JW Atkinson RL et al.Weight loss with self-help compared with a structured commercial program: a randomized trial.JAMA. 2003; 289: 1792-1798Crossref PubMed Scopus (366) Google Scholar and further improve the viability of prolonged intervention programmes. I work for a government organisation (Commonwealth Scientific and Industrial Research Organisation), which has existing relationships with and has done work for multiple nutrition and weight management entities, and have personally worked on the development or evaluation of weight management programmes with external companies or organisations, including Bupa Health Foundation, Probiotec, and SP Health. Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trialFor adults with overweight or obesity, referral to this open-group behavioural weight-loss programme for at least 12 weeks is more effective than brief advice and self-help materials. A 52-week programme produces greater weight loss and other clinical benefits than a 12-week programme and, although it costs more, modelling suggests that the 52-week programme is cost-effective in the longer term. Full-Text PDF Open Access