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 doi: https://doi.org/10.1136/bmj.d6500 (Published 03 November 2011) Cite this as: BMJ 2011;343:d6500
All rapid responses
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.
Competing interests: No competing interests
We read with interest Jolly and others’ randomised controlled trial of the effectiveness of various weight-management programmes offered in primary care.[1] In the study group, Weight Watchers achieved larger weight losses than other programmes. The study raises several questions about the interpretation of randomised controlled trial results when recruitment is low and patients demonstrate treatment preference. We have three interrelated observations to make on the interpretation of the results Jolly and others present.
The first is that low patient motivation and strong patient preference influenced participation in the trial. As the accompanying editorial highlights,[2] the majority (88.5%) of eligible patients did not elect to participate in the trial. The absence of these patients leads to bias and restricts the generalisation of the study’s findings. The reported proportions of patients who achieved clinically significant weight losses at one year (for example, 31.0% at Weight Watchers) might therefore represent 3.6% of all patients that a GP referred for such weight management.
The second is that selection biases for trial participants may have led to an unrepresentative sample. Attendance is one of the major predictors of successful weight loss within weight management programmes and patients who attend programmes are not the same as those who drop out.[3] It is unclear what selection biases might have affected the final study population but it seems reasonable to suggest that trial participants were not typical of the sampling frame. Participants may have been motivated by the possibility of obtaining free access to a commercial weight management programme and experienced “resentful demoralization” when offered NHS services.[4]
The third is that the conclusions of the analysis of the effects of patient choice are unsound because there were insufficient numbers of patients (only 3 patients chose general practice for example) with which to draw informative conclusions. We feel that the authors’ conclusions, repeated in the Abstract without reference to the small number of patients, is misleading. It is not surprising that interactions between choice and programme were not found to be statistically significant, but it would have been helpful to have seen what they were. In open randomised trials, patients’ treatment preferences should be ascertained prior to randomisation.[5]
[1] Jolly K, Lewis A, Beach J, Denley J, Adab P, Deeks J and others. 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 doi: 10.1136/bmj.d6500
[2] Truby H. What makes a weight loss programme successful? BMJ 2011;343:d6629
[3] Honas JJ, Early JL, Frederickson DD, O’Brien MS. Predictors of attrition in a large clinic-based weight-loss program. Obesity 2003;11:888-894.
[4] Bradley C. Designing medical and educational intervention studies. Diabetes Care 1993;16:509–18.
[5] Preference Collaborative Review Group. Patients’ preferences within randomised trials: systematic review and patient level meta-analysis. BMJ 2008; 337 doi: 10.1136/bmj.a1864.
Competing interests: We have evaluated the Counterweight programme and other providers’ weight management programmes but we have no financial interests in the Counterweight Company or any others.
Dear Editor:
I read the report comparing various commercial and NHS-sponsored weight loss programs with interest. An accompanying editorial suggested that NHS staff trained to do obesity counseling were less effective than Weight Watchers staff because NHS staff were less experienced at such counseling than Weight Watchers staff. While that may be part of the explanation there is an additional explanation that bears consideration. With guidance from Barbara Rolls, first Weight Watchers and then Jenny Craig1 recently adopted treatment policies that encourage increased consumption of high-satiating foods, especially fruits, vegetables and whole grains, foods that tend to fill people up faster with fewer calories than conventional foods.2 Overweight women taught to eat more fruit and vegetables in addition to eating less fat have been shown in a randomized, controlled trial to lose more weight and nonetheless experience less hunger than women in a control condition featuring a traditional low-fat, energy-restrictive diet.3 The U.S. Department of Agriculture recently released MyPlate.gov, a replacement for MyPyramid.gov.4 MyPlate.gov explicitly encourages Americans who want to improve their weight control efforts to eat more of some foods, particularly water-bearing fruits, vegetables, and whole grain products because of their value in promoting satiation during a meal with fewer calories. Current UK clinical guidelines for counseling patients about strategies to lose excess weight make no mention of the behavioral benefits of encouraging such patients to eat high-satiation foods.5 When NHS staff are trained to include messages about the behavioral benefits of eating more high-satiating foods, they may achieve longer-lasting impact on their patients’ obesity risk.
Author:
William J. McCarthy, Ph.D.
Professor of Health Services
UCLA School of Public Health
A2-125 CHS, mc 690015
650 Charles Young Drive,
Los Angeles, CA 90095, USA
wmccarth@ucla.edu
References:
1. Rock CL, Flatt SW, Sherwood NE, Karanja N, Pakiz B, Thomson CA. Effect of a Free Prepared Meal and Incentivized Weight Loss Program on Weight Loss and Weight Loss Maintenance in Obese and Overweight Women A Randomized Controlled Trial. JAMA-J. Am. Med. Assoc. 2010;304(16):1803-11.
2. Rolls B. The Volumetrics Eating Plan. New York: Harper, 2005.
3. Ello-Martin JA, Roe LS, Ledikwe JH, Beach AM, Rolls BJ. Dietary energy density in the treatment of obesity: a year-long trial comparing 2 weight-loss diets. Am. J. Clin. Nutr. 2007;85(6):1465-77.
4. U.S. Department of Agriculture. MyPlate.gov, 2011. Accessed from: http://www.choosemyplate.gov/
5. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children 2006. Accessed from http://www.nice.org.uk/nicemedia/live/11000/38294/38294.pdf
Competing interests: No competing interests
Prevention of Obesity is now the Priority
The results of treatment of obesity by Jolly and colleages(1)were poor. Only 11% of overweight patients accepted the invitation of their family doctors to attend a slimming clinic and only 21% of those who attended the NHS Size Down clinics and only 15.7% of those who attended GP obesity clinics had a 5% sustained weight loss over a year. Would oncologists accept similar results for their patients? Perhaps different approaches to prevention should be explored.
About the age of 10 months most babies refuse to eat foods which previously they had taken eagerly. This normally coincides with a sharp fall in the BMI and a change from the chubby cherub to the leaner adult shape. Parents, especially those with a first child, become anxious. Initially they think that the infant is acutely ill and later that she will become ill if she continues to become thinner. In desperation they give foods that are more tasty, but contain more sugar, salt or fat. The extra food, which is not needed for normal growth, may cause a permanent addiction to foods with a strong taste and obesity.
The scope of the last NICE report on obesity(2) began at the age of two years. Another report covering the period of birth to two years may reveal more effective approaches to the management of the present epidemic of obesity.
(1) BMJ 2011; 343: d6500
(2) 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)
Competing interests: No competing interests
Jolly et al’s results suggest that Weight Watchers is successful at achieving weight reduction immediately after programme completion and on follow-up at one year1. We have just concluded an evaluation study of a NHS-funded Weight Watchers service which gave similar results at 23 months.
108 participants from our original pilot group, who accessed Weight Watchers in June 2009, were recently invited to return postal questionnaires requesting their current weight (43.5% return rate). This was followed-up with telephone calls and finally requests from GP records regarding non-responders (weights were accepted only if recorded within 6 months of enquiry). We successfully followed-up 81 (75%) of the cohort to an average of 693 days [s.d. 61], and excluded those lost to follow-up from further analysis. Mean weight at baseline (101.7kg [s.d. 19.4]) and at 12-week course completion (97.4kg [s.d. 19.0]) were significantly different (p<0.001) – a change of -4.3kg which almost matches Jolly et al’s finding1. Mean follow-up weight (97.5kg [s.d. 19.4]) was similar to course-end weight, and was likewise significantly different to baseline (p<0.001). These relationships were mirrored by BMI comparisons, with a significant difference between baseline BMI (38.2 [s.d. 6.4]) and both the course-completion BMI (36.6 [s.d. 6.7], p<0.001) and follow-up BMI (36.6 [s.d. 6.5], p<0.001).
Despite the obvious limitations of this small mixed-source dataset based largely on self-reported weight, these results resonate with Jolly et al’s findings and furthermore suggest that weight reduction achieved on completion of Weight Watchers is maintained to almost two years. The clinical benefit of relatively small changes in weight in people with a high BMI, and the longer-term outcomes of alternative weight loss programmes both need careful consideration before contemplating broader inclusion of Weight Watchers or other weight loss services in public health strategies against obesity.
1. Jolly K, Lewis A, Beach J, Denley J, Adab P, Deeks JJ, Daley A, Aveyard P. 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
Competing interests: No competing interests
As your editorial [1] observes, commercial slimming companies have invested significantly to develop their programmes so could be expected to be at least as effective as other approaches to weight loss. Though Lighten Up participants had their participation costs paid by the study, others using commercial slimming companies pay for themselves. That suggests that they are motivated to lose weight. And once they have paid, they have an interest in ensuring a positive outcome which in itself may make that outcome, sustained weight loss, more likely. Perhaps the key role for primary care in the management of obesity should be to provide patients with information that will motivate them to take action, whether with or without the support of the commercial slimming companies.
[1] BMJ 2011:343:d7188
Competing interests: No competing interests
Reaching the parts that health services weight management resources cannot reach.
Wendy L Wrieden, Lecturer in Nutrition, Robert Gordon University, Aberdeen, Alison Avenell, Clinical Senior Lecturer, University of Aberdeen
We welcome the publication of recent results of “Lighten up”, a randomised trial in a UK setting (Birmingham) that demonstrated the effectiveness of commercial weight management programmes (CWMP).1 This provides further evidence for the NHS to implement further partnerships with CWMP that follow NICE2 guidelines. The proportion of obese adults continues to increase and with it a massive burden of health and social care costs due to associated chronic disease.3
In Scotland, to our knowledge the only health board that has reported on such a collaboration is NHS Ayrshire and Arran.4 We requested details of lifestyle weight management programmes available across Scotland from individual health board areas and evidence informed CWMP (following NICE2 and Scottish5 national guidelines). Over the period requested (2008 – 2009) programmes that were available through the commercial sector in Scotland had a far greater reach than programmes run by the NHS.6 Reach was calculated as the number of people recruited onto the programmes, or for commercial programmes which are ongoing the maximum number of people attending weekly as a % of the target population (overweight and obese) in an area. For example, for CWMP this was 1.6% compared with 0.15% for NHS led Counterweight, taking figures from across Scotland.
As Truby points out in her editorial, the NHS can learn lessons from the commercial companies both on the level of investment in the workforce and how to deliver services more acceptable to consumers.7 NHS led programmes such as Counterweight and NHS Size Down can be effective.1,8 The ‘Lighten up’ results and others show that the commercial programmes, particularly Weight Watchers, can have better success than primary care at one year.1,9 It may be that using NHS resources to develop many individual local programmes might be better directed to help people who are more obese with existing comorbidities. Use of the commercial sector, either through slimming on referral schemes or by advising and providing information as to where such groups are available, is an avenue that must now be developed.
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. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children;2006.
3. UK Government Office for Science. Foresight. Tackling obesities: future choices - project report;2007.
4. Smith F. NHS Ayrshire and Arran Report on Weight Watchers on referral pilot in East, North and South Ayrshire;2009.
5. Scottish Intercollegiate Guidelines Network. Management of obesity: a national clinical guideline;2010. Report No.115.
6. Wrieden W, Avenell A. A review of lifestyle weight management options in Scotland which meet best practice. Proc Nutr Soc 2010;69 (OCE6):E449.
7. Truby H, Bonham M. What makes a weight loss programme successful? BMJ 2011;343:d6629.
8. Ross H, Laws R, Reckless J, Lean M, Counterweight Project Team. Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement. Br J Gen Pract 2008; 58:548-54.
9. Jebb SA, Ahern AL, Olson AD, Aston LM, Holzapfel C, Stoll J, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011;378:1485-92.
Competing interests: WW has an outstanding request with a commercial weight management company with regard to potential funding for a Slimming on Referral trial
The Lighten Up trial, (1) plus the recent paper by Jebb and colleagues (2) showing that community weight loss services are more successful than traditional GP care raises important issues for primary care weight management. Unless these issues are promptly addressed, there is a risk that some will interpret these findings as a get-out clause for reluctant GPs to avoid weight management altogether, whilst confusing those GPs who offer an in-house weight management clinic (WMC) over whether to continue. Both papers clarify what GPs should not be doing – running weight management clinics as a first line approach.
But the Foresight (3) report called loudly for development of comprehensive team management – responsibility for all – and contrary to the suggestion in the linked editorial, (4) GPs do not need to compete with commercial WMCs but work with them to help more patients access appropriate support and be in the right frame of mind for that support to be beneficial. The role of the GP is different and complementary to community weight services and should reflect the unique skills and specific patient knowledge that GPs have. Lighten up achieved 11.5% uptake leaving 88.5% of those targeted presumably with unmet needs. GPs could fruitfully develop a role in sensitively raising awareness of the relevance of weight to health, assessing motivation and emotional fragility in order to ensure that chosen goals are feasible and will not erode self esteem further, (how often have we colluded with unrealistic targets and set our patients up to fail?) and to increase the numbers of patients that are signposted to local community services as a first line.
Further debate and research is needed on how best to manage those patients that are unsuccessful or for whom community services are unsuitable, and interested GPs could develop a role here. Development of clearer and funded bariatric pathways will complement this first line approach. Obesity training and educational resource developments are a high priority and the Royal Colleges are now actively engaged in both.
Rachel Pryke
GP
RCGP Clinical Champion for Nutrition for Health
Winyates Health Centre
Redditch, Worcestershire B98 0NR
rachelgpryke@btinternet.com
References
1. Jolly K, Lewis A, Beach J, 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 doi: 10.1136/bmj.d6500
2. Jebb SA, Ahern AL, Olson AD, Aston LM, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011 Oct 22: 3378 (9801): 1485-92. Epub 2011 Sep 7
3. Government Office for Science. Foresight: Tackling Obesities: Future Choices – Modeling Future Trends in Obesity and the Impact on Health, 2nd Edition. 2007 www.foresight.gov.uk/Obesity/14.pdf
4. Truby H, Bonham M. What makes a weight loss programme successful? BMJ 2011;343:d6629
Competing interests: No competing interests
The Lighten Up trial, (1) plus the recent Lancet paper (2) showing that community weight loss services are more successful than traditional GP care raises important issues for primary care weight management. Unless these issues are promptly addressed, there is a risk that some will interpret these findings as a get-out clause for reluctant GPs to avoid weight management altogether, whilst confusing those GPs who offer an in- house weight management clinic (WMC) over whether to continue. Both papers clarify what GPs should not be doing - running weight management clinics as a first line approach.
But the Foresight (3) report called loudly for development of comprehensive team management - responsibility for all - and contrary to the suggestion in the linked editorial, (4) GPs do not need to compete with commercial WMCs but work with them to help more patients access appropriate support and be in the right frame of mind for that support to be beneficial. The role of the GP is different and complementary to community weight services and should reflect the unique skills and specific patient knowledge that GPs have. Lighten up achieved 11.5% uptake leaving 88.5% of those targeted presumably with unmet needs.
GPs could fruitfully develop a role in sensitively raising awareness of the relevance of weight to health, assessing motivation and emotional fragility in order to ensure that chosen goals are feasible and will not erode self esteem further, (how often have we colluded with unrealistic targets and set our patients up to fail?) and to increase the numbers of patients that are signposted to local community services as a first line.
Further debate and research is needed on how best to manage those patients that are unsuccessful or for whom community services are unsuitable, and interested GPs could develop a role here. Development of clearer and funded bariatric pathways will complement this first line approach. Obesity training and educational resource developments are a high priority and the Royal Colleges are now actively engaged in both.
Rachel Pryke GP, RCGP Clinical Champion for Nutrition for Health
Winyates Health Centre Redditch, Worcestershire B98 0NR rachelgpryke@btinternet.com
References 1. Jolly K, Lewis A, Beach J, 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 doi: 10.1136/bmj.d6500
2. Jebb SA, Ahern AL, Olson AD, Aston LM, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011 Oct 22: 3378 (9801): 1485-92. Epub 2011 Sep 7
3. Government Office for Science. Foresight: Tackling Obesities: Future Choices - Modeling Future Trends in Obesity and the Impact on Health, 2nd Edition. 2007 www.foresight.gov.uk/Obesity/14.pdf
4. Truby H, Bonham M. What makes a weight loss programme successful? BMJ 2011;343:d6629
Competing interests: None declared
Competing interests: No competing interests
Re: 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.
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Competing interests: No competing interests