NIHR Signal A supported web-based programme helps people lose weight in the short term

Published on 9 May 2017

A web-based programme (POWeR) with nurse support helped about 30% of people lose at least 5% of their body weight, maintained for at least 12 months. By comparison, twenty percent of people achieved this with an online information sheet only.  This research does not tell us whether POWeR alone would have provided the same benefit

POWer+ helped more people achieve short-term weight loss but the average weight loss of about 3-4 kg after 12 months was statistically similar for those given information only. The healthy eating online materials tested had previously been shown to help people to control their weight, without expert advice.

The NHS needs low-cost weight loss programmes to tackle the burden of obesity-related disease. This NIHR research showed that the web programme, with phone or email support from nurses, had a modest benefit and was probably cost-effective.  It represents one option that could be offered to patients.

A supported web-based programme helps people lose weight in the short term

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Why was this study needed?

Latest figures show that 63% of adults were overweight or obese in 2015, defined as having a body mass index (BMI) of 25 or over. Obesity is directly linked to illnesses including type 2 diabetes, fatty liver disease, hypertension, gallstones and gastro-oesophageal reflux disease, and indirectly linked to many more, including an estimated 20% of cancers.

Intensive, individual long-term support programmes, community-based weight loss groups and societal/environmental/policy changes can work to reduce obesity. However, obesity management usually takes place in primary care, where lack of time and specially-trained staff make intensive support challenging.

Options are needed to engage people in losing weight, with minimal healthcare professional support. Therefore the researchers aimed to assess a 24-session online weight management programme called POWeR+ which they had created. It uses behaviour change techniques to encourage people to track their weight and form healthy eating habits. People get tailored feedback and encouragement from a nurse.

What did this study do?

In this three-arm randomised controlled trial, 818 people with a BMI of 30 or higher were recruited from 56 general practices via postal invitations. They were allocated to groups who were told to either:

  • read two online advice sheets about healthy food swaps and eating five portions of fruit and vegetables a day
  • access the online POWeR+ programme, plus have up to seven face-to-face meetings with a nurse
  • access the POWeR+ programme, plus have up to five email or phone contacts with a nurse.

Everyone had a baseline nurse assessment. Follow-up appointments were offered after six and 12 months.

Nearly 20% of participants did not attend follow-up and this was similar between groups.

What did it find?

  • The three groups all lost weight, with average weight loss at 12 months of 2.65kg for the control group, 3.84kg for the POWeR+ with face-to-face support programme and 3.21kg for the POWeR+ with email or phone support programme. Differences were not statistically significant.
  • The proportion of people who had lost at least 5% of body weight at 12 months was statistically significant for the POWeR+ group with email and phone support compared to control. At 12 months 20.8% of people in the control group had lost 5% of body weight, 29.2% for the POWeR+ with face to face group (risk ratio [RR] 1.56, 95% CI 0.96 to 2.51) and 32.4% for the POWeR+ with email or phone support group (RR 1.82, 95% CI 1.21 to 2.74).
  • Around 30% of people in each POWeR+ group did not use the available nurse support.

What does current guidance say on this issue?

NICE has three guidelines addressing obesity prevention, obesity identification and management, and weight management. The latter recommends that obese people should be referred to a lifestyle weight management programme. Among other recommendations, it says programmes should do the things below.

  • Address dietary intake, physical activity levels and behaviour change.
  • Be developed with input from a registered dietitian, registered practitioner psychologist and a qualified physical activity instructor.
  • Continue for at least three months, with weekly or fortnightly sessions which include a 'weigh-in' at each session, led by trained staff.
  • Use a variety of behaviour-change methods, including problem solving; goal setting; how to carry out tasks or activities; planning to provide social support or make changes to the social environment; self-monitoring of weight and behaviours; and feedback on performance.
  • Set individual, achievable weight-loss goals, with agreed dietary targets tailored to individual needs.

What are the implications?

The POWeR plus programme might be a relatively low-cost way to aid weight loss in the community, without requiring face to face support from expert dieticians. The study showed it worked at least as well as a brief intervention which had previously been shown to aid weight loss.   

However, we don’t know how it might directly compare to other weight loss programmes such as community-based group programmes for lifestyle change. These can result in an additional loss of about 3kg over control at one year. Uptake and engagement with the intervention was challenging and this is typical for these types of programme.  We don’t know whether the web site would be helpful without the nurse support.

The difference in weight loss compared to control at one year was not significant, which is a drawback for implementation. Other interventions may be required in addition to these web-based ones to ensure that any weight loss is sustained in the long term.

Citation and Funding

Little P, Stuart B, Hobbs FR, et al. Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (PositiveOnline Weight Reduction). Health Technol Assess. 2017;21(4):1-62.

This study was funded by the HTA Programme of the National Institute for Health Research.

Bibliography

Little P, Stuart B, Hobbs FR, et al. An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2016;4(10):821-8.

NICE. Obesity: identification, assessment and management. CG189. London: National Institute for Health and Care Excellence; 2014.

NICE. Obesity prevention. CG43. London: National Institute for Health and Care Excellence; 2006.

NICE. Weight management: lifestyle services for overweight or obese adults Public health guideline. PH53. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Latest figures show that 63% of adults were overweight or obese in 2015, defined as having a body mass index (BMI) of 25 or over. Obesity is directly linked to illnesses including type 2 diabetes, fatty liver disease, hypertension, gallstones and gastro-oesophageal reflux disease, and indirectly linked to many more, including an estimated 20% of cancers.

Intensive, individual long-term support programmes, community-based weight loss groups and societal/environmental/policy changes can work to reduce obesity. However, obesity management usually takes place in primary care, where lack of time and specially-trained staff make intensive support challenging.

Options are needed to engage people in losing weight, with minimal healthcare professional support. Therefore the researchers aimed to assess a 24-session online weight management programme called POWeR+ which they had created. It uses behaviour change techniques to encourage people to track their weight and form healthy eating habits. People get tailored feedback and encouragement from a nurse.

What did this study do?

In this three-arm randomised controlled trial, 818 people with a BMI of 30 or higher were recruited from 56 general practices via postal invitations. They were allocated to groups who were told to either:

  • read two online advice sheets about healthy food swaps and eating five portions of fruit and vegetables a day
  • access the online POWeR+ programme, plus have up to seven face-to-face meetings with a nurse
  • access the POWeR+ programme, plus have up to five email or phone contacts with a nurse.

Everyone had a baseline nurse assessment. Follow-up appointments were offered after six and 12 months.

Nearly 20% of participants did not attend follow-up and this was similar between groups.

What did it find?

  • The three groups all lost weight, with average weight loss at 12 months of 2.65kg for the control group, 3.84kg for the POWeR+ with face-to-face support programme and 3.21kg for the POWeR+ with email or phone support programme. Differences were not statistically significant.
  • The proportion of people who had lost at least 5% of body weight at 12 months was statistically significant for the POWeR+ group with email and phone support compared to control. At 12 months 20.8% of people in the control group had lost 5% of body weight, 29.2% for the POWeR+ with face to face group (risk ratio [RR] 1.56, 95% CI 0.96 to 2.51) and 32.4% for the POWeR+ with email or phone support group (RR 1.82, 95% CI 1.21 to 2.74).
  • Around 30% of people in each POWeR+ group did not use the available nurse support.

What does current guidance say on this issue?

NICE has three guidelines addressing obesity prevention, obesity identification and management, and weight management. The latter recommends that obese people should be referred to a lifestyle weight management programme. Among other recommendations, it says programmes should do the things below.

  • Address dietary intake, physical activity levels and behaviour change.
  • Be developed with input from a registered dietitian, registered practitioner psychologist and a qualified physical activity instructor.
  • Continue for at least three months, with weekly or fortnightly sessions which include a 'weigh-in' at each session, led by trained staff.
  • Use a variety of behaviour-change methods, including problem solving; goal setting; how to carry out tasks or activities; planning to provide social support or make changes to the social environment; self-monitoring of weight and behaviours; and feedback on performance.
  • Set individual, achievable weight-loss goals, with agreed dietary targets tailored to individual needs.

What are the implications?

The POWeR plus programme might be a relatively low-cost way to aid weight loss in the community, without requiring face to face support from expert dieticians. The study showed it worked at least as well as a brief intervention which had previously been shown to aid weight loss.   

However, we don’t know how it might directly compare to other weight loss programmes such as community-based group programmes for lifestyle change. These can result in an additional loss of about 3kg over control at one year. Uptake and engagement with the intervention was challenging and this is typical for these types of programme.  We don’t know whether the web site would be helpful without the nurse support.

The difference in weight loss compared to control at one year was not significant, which is a drawback for implementation. Other interventions may be required in addition to these web-based ones to ensure that any weight loss is sustained in the long term.

Citation and Funding

Little P, Stuart B, Hobbs FR, et al. Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (PositiveOnline Weight Reduction). Health Technol Assess. 2017;21(4):1-62.

This study was funded by the HTA Programme of the National Institute for Health Research.

Bibliography

Little P, Stuart B, Hobbs FR, et al. An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2016;4(10):821-8.

NICE. Obesity: identification, assessment and management. CG189. London: National Institute for Health and Care Excellence; 2014.

NICE. Obesity prevention. CG43. London: National Institute for Health and Care Excellence; 2006.

NICE. Weight management: lifestyle services for overweight or obese adults Public health guideline. PH53. London: National Institute for Health and Care Excellence; 2014.

Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (Positive Online Weight Reduction)

Published on 25 January 2017

Little P, Stuart B, Hobbs RFD, Kelly J, Smith ER, Bradbury KJ

Health Technology Assessment Volume 21 Issue 4 , 2017

Background Behavioural counselling with intensive follow-up for obesity is effective, but in resource-constrained primary care settings briefer approaches are needed. Objectives To estimate the clinical effectiveness and cost-effectiveness of an internet-based behavioural intervention with regular face-to-face or remote support in primary care, compared with brief advice. Design Individually randomised three-arm parallel trial with health economic evaluation and nested qualitative interviews. Setting Primary care general practices in the UK. Participants Patients with a body mass index of ≥ 30 kg/m2 (or ≥ 28 kg/m2 with risk factors) identified from general practice records, recruited by postal invitation. Interventions Positive Online Weight Reduction (POWeR+) is a 24-session, web-based weight management intervention completed over 6 months. Following online registration, the website randomly allocated participants using computer-generated random numbers to (1) the control intervention (n = 279), which had previously been demonstrated to be clinically effective (brief web-based information that minimised pressure to cut down foods, instead encouraging swaps to healthier choices and increasing fruit and vegetables, plus 6-monthly nurse weighing); (2) POWeR+F (n = 269), POWeR+ supplemented by face-to-face nurse support (up to seven contacts); or (3) POWeR+R (n = 270), POWeR+ supplemented by remote nurse support (up to five e-mails or brief telephone calls). Main outcome measures The primary outcome was a modelled estimate of average weight reduction over 12 months, assessed blind to group where possible, using multiple imputation for missing data. The secondary outcome was the number of participants maintaining a 5% weight reduction at 12 months. Results A total of 818 eligible individuals were randomised using computer-generated random numbers. Weight change, averaged over 12 months, was documented in 666 out of 818 participants (81%; control, n = 227; POWeR+F, n = 221; POWeR+R, n = 218). The control group maintained nearly 3 kg of weight loss per person (mean weight per person: baseline, 104.4 kg; 6 months, 101.9 kg; 12 months, 101.7 kg). Compared with the control group, the estimated additional weight reduction with POWeR+F was 1.5 kg [95% confidence interval (CI) 0.6 to 2.4 kg; p = 0.001] and with POWeR+R was 1.3 kg (95% CI 0.34 to 2.2 kg; p = 0.007). By 12 months the mean weight loss was not statistically significantly different between groups, but 20.8% of control participants, 29.2% of POWeR+F participants (risk ratio 1.56, 95% CI 0.96 to 2.51; p = 0.070) and 32.4% of POWeR+R participants (risk ratio 1.82, 95% CI 1.31 to 2.74; p = 0.004) maintained a clinically significant 5% weight reduction. The POWeR+R group had fewer individuals who reported doing another activity to help lose weight [control, 47.1% (64/136); POWeR+F, 37.2% (51/137); POWeR+R, 26.7% (40/150)]. The incremental cost to the health service per kilogram weight lost, compared with the control group, was £18 (95% CI –£129 to £195) for POWeR+F and –£25 (95% CI –£268 to £157) for POWeR+R. The probability of being cost-effective at a threshold of £100 per kilogram was 88% and 98% for POWeR+F and POWeR+R, respectively. POWeR+R was dominant compared with the control group. No harms were reported and participants using POWeR+ felt more enabled in managing their weight. The qualitative studies documented that POWeR+ was viewed positively by patients and that health-care professionals generally enjoyed supporting patients using POWeR+. Study limitations Maintenance of weight loss after 1 year is unknown. Future work Identifying strategies for longer-term engagement, impact in community settings and increasing physical activity. Conclusion Clinically valuable weight loss (> 5%) is maintained in 20% of individuals using novel written materials with brief follow-up. A web-based behavioural programme and brief support results in greater mean weight loss and 10% more participants maintain valuable weight loss; it achieves greater enablement and fewer participants undertaking other weight-loss activities; and it is likely to be cost-effective. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 4. See the NIHR Journals Library website for further project information.

Expert commentary

To effectively modify behaviour requires reinforcement and time - something in short supply in primary care! And yet, weight management in people who are overweight, particularly in the presence of significant co-morbidities, is critical for health and wellbeing as well as reducing long term costs to the health system.

Given the complexity of the issues involved, health professionals need a range of management options which can be discussed and agreed with the patient. Novel approaches to weight management, which are both clinically and cost effective, are to be welcomed and will provide additional management options in a resource limited NHS.

Anthony H Barnett, Emeritus Professor of Medicine, University of Birmingham and Heart of England NHS Foundation Trust, Birmingham

Expert commentary

Digital interventions are an attractive option to treat obesity, but are they effective? In this web-based programme, supported by modest contact with nurses, weight loss at six months was significantly greater than control, but not at 12 months, since the intervention group regained weight while the control group did not. The control group success suggests these trial participants were motivated to lose weight and the likely outcome in a more general population who are overweight is unknown. However, this trial is further evidence that well structured, brief interventions with follow-up can stimulate successful weight loss, with or without web-based support.

Susan Jebb, Professor of Diet and Population Health, University of Oxford