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

We read with great interest the paper by Jolly et al (2011)1 which compared a range of commercial and primary care-led weight reduction programmes. The rise in obesity to epidemic proportions2 requires multidimensional strategies 3, hence it is useful to make comparisons between differing settings and methods of supporting weight reduction.

We were particularly interested in the findings from the pharmacy setting. Community pharmacy premises have been identified as appropriate settings for early identification and management of obesity3, 4. The strengths of pharmacy include easy accessibility, availability in a variety of differing locations and long opening hours, providing increased convenience for consumers. Pharmacies have the further key strength of being able to identify those at risk from overweight but who may not be considering weight loss (opportunistic recruitment).
There are few published studies of primary care-led weight management services (WMS), however the Counterweight Project demonstrated a statistically significant weight loss at both 12 and 24 months from an intervention delivered by practice nurses.5 Our experience of a pharmacy-based weight management service also showed positive results which we consider are relevant to the current debate.
City and Hackney Primary Care Trust launched a pharmacy-based WMS in 2008 which was independently evaluated one year later. The service was provided by trained and accredited community pharmacists, offering one-to-one support. Consultations were based on the principles of motivational interviewing and evidence-based recommendations for the management of obesity including, where appropriate, referral to GP, dietician, exercise programme or other specialist PCT-based WMS. Orlistat could be supplied in accordance with national guidelines via a patient group directive to those achieving the required level of weight loss at 12 weeks. Most participants in the service were visiting the pharmacy for other reasons and were recruited opportunistically.

Data from 106 participants attending nine pharmacies, analysed on an intention to treat basis, showed that 78% (84) lost weight by week 12 with a mean (SD) weight loss of 2.6 (2.9) kg. In total, 26% of all participants achieved the target weight loss of 5%. At 24 weeks, 79% of patients had lost weight, 3% had achieved the target weight loss of 10% and mean weight loss was 2.9 (3.3) kg. In addition to this statistically significant (p <0.005) weight loss and BMI reduction from baseline at weeks 12 and 24, there were also improvements in waist circumference (p= 0.001) and blood pressure (p<0.05) but not in pulse (p= 0.52).

Hence, although both this service and that established by the Counterweight Project were not evaluated in controlled trials, both found significant and promising positive results from primary care-based WMS. Both however also noted variation in the success rates achieved by individual practices. No data are available from the Jolly study on whether they too found this to be the case with either of the primary care services. They do suggest several factors which could contribute to the overall lower effectiveness of these compared to commercial services, including less training and experience, one-to-one as opposed to group sessions and difficulties in booking sessions. We suggest, from our experience, that other possible reasons may include differing staffing levels, facilities, willingness to be flexible in providing appointments and indeed overall motivation between pharmacies. In City and Hackney the WMS was linked to a previously well-documented successful program, the smoking cessation service, hence staff had already demonstrated relevant transferrable skills. One of the acknowledged strengths of pharmacy staff is their ability to support adherence to therapies and the study by Jolly et al demonstrates this, since only the pharmacy group showed any change in activity at programme end. The participants in this trial were respondents to an invitation letter from their general practice, which achieved a low response rate of 11.5%, hence, as the authors suggest, they are likely to have been highly motivated. Our WMS in City and Hackney recruited participants opportunistically through community pharmacies, hence they may be less motivated, yet significant weight loss was still achieved.
It is interesting that Jolly et al found no statistically significant difference in weight loss between participants who chose their programme and those who were randomised to the same programme. We feel that the results should be interpreted with caution, since while 71 of the 100 in the ‘choice arm’ chose the commercial services, 16 chose the dietician-led Size down program, only 3 chose general practitioners and 10 a pharmacy. Hence the numbers who chose their programme in comparison to those randomised to that programme were particularly small in the GP and pharmacy groups. We do recognise that a community pharmacy is not the first choice of most people wishing to lose weight, as has been shown previously,7 however there is also a lack of awareness among the public that pharmacies are able to provide such services8, while the experiences of those who have used pharmacy public health services are invariably positive.9 Furthermore, it is possible that men, noted to be a hard to reach population, may in fact prefer the confidentiality of a one to one setting compared to group-based sessions where women are overrepresented, no matter how ‘male-friendly’ they may try to be.

We agree that primary care services are not able to dedicate as much time and focus to weight management as commercial programmes, however they have the important advantage of being able to address co-morbidities or other factors associated with or consequences of overweight. Hence there are advantages and disadvantages to the different models and each has a contribution to make to the obesity epidemic, based on their strengths.
Jolly et al make an interesting suggestion that primary care practitioners may have limited self-belief in their ability to effect positive change, which highlights the need for enhancing motivation and providing better training for practitioners with a real interest in providing such services. Furthermore, successful cases need to be showcased, for others to see the positive changes in weight loss which can be achieved in primary care.
Yours

Funmi Oduniyi, Clinical Lecturer in Pharmacy Practice
Catherine Dewsbury, Clinical Lecturer in Pharmacy Practice
Janet Krska, Professor of Pharmacy Practice
Jonathan Mason, Head of prescribing, City and Hackney Teaching PCT / National Clinical Director for Primary Care and Community Pharmacy

Email correspondence to o.oduniyi@gre.ac.uk

References
1. Jolly K, Lewis A, Beach J, Denley J, Adab P, Deeks JJ, et al. 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 2011;343:d6500.
2. Foresight. Tackling Obesities: Future Choices – Project Report. Government Office for Science 2007 [Online] Available at: http://www.foresight.gov.uk/Obesity/14.pdf. Accessed 6 January 2010
3. National Institute for Health and Clinical Excellence. Obesity. Guidance on the prevention, identification, and management of overweight and obesity in adults and children. NICE, 2006 (Clinical Guidelines 43)
4. Department of Health. ‘Pharmacy in England: building on strengths - delivering the future’. London: Department of Health 2008 [Online] Available at: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicati... Accessed 10 January 2009
5. Counterweight Project Team. Evaluation of the Counterweight Programme for obesity management in primary care. Br J Gen Pract 2008;58:548-54.
6. Oduniyi, O, Dewsbury, C. Corlett, S. City and Hackney Teaching Primary Care Trust Pharmacy Weight Management Service . Evaluation report. Chatham: Medway School of Pharmacy 2010
7. Krska J, Lovelady C, Connolly D, Parmar S, Davies MJ (2010) Community pharmacy contribution to weight management: identifying opportunities. Int J Pharm Pract 18 (1): 7-12.
8. Krska J, Morecroft CW. Views of the general public on the role of pharmacy in public health. J Pharm Health Serv Res 2010; 1(1): 33-38
9. Anderson C, Blenkinsopp A, Armstrong M. (2009) Report 7: The contribution of community pharmacy to improving the public’s health: Summary report of the literature review 1990-2007. PharmacyHealthLink and Royal Pharmaceutical Society of Great Britain.