NIHR Signal A group weight loss programme shows promise compared with usual approach

Published on 21 March 2017

A new, intensive NHS group weight management programme was more effective than the more common individual sessions with a practice nurse. In an NIHR-funded trial based in deprived districts in East London, people who took part in the primary care group-based programme lost nearly 2kg more than those who had individual sessions with a nurse. Most of the participants were women, and over a third was from black and minority ethnic groups.

Despite the greater intensity and duration of the group programme compared to the individual sessions with a nurse, the cost per participant was similar, £195 versus £176, respectively.

On a national scale, cost effective long-term weight management interventions are needed urgently to help deal with the problems of increasing obesity. This group approach shows promise, but needs further evaluation in men, different ethnic groups and different areas.

A group weight loss programme shows promise compared with usual approach

Why was this study needed?

Costs of treating obesity and associated health conditions continue to rise. Public Health England estimates that one in four adults is obese (BMI ≥ 30kg/m2), costing society £27 billion per year, including £19 billion being spent on NHS care and obesity medications. Obesity is very prevalent in black and minority ethnic groups, especially amongst women, and the highest rates of obesity are found in those with the lowest level of income and in the most deprived areas.

Many approaches have been tried in primary care for reducing obesity but at best weight loss tends to be modest and weight is often regained after the intervention stops. Intensive behavioural approaches may help but require a lot of input from staff and commitment from participants.

This trial aimed to evaluate the long-term effects of a group based weight management plan involving weekly tasks and tools to lose weight and then maintain a healthier weight.

What did this study do?

This randomised controlled trial compared a group Weight Action Programme (WAP) with usual practice delivered by a nurse. The trial recruited 330 adults, 72% female, with a BMI between 30kg/m2 to 45kg/m2 from six boroughs in London.

The WAP involved eight weekly group sessions on self-regulation (e.g. food diaries), motivational techniques (e.g. incremental targets), a peer support network, and dietary and exercise advice and monitoring by pedometer. Ten monthly sessions then focussed on maintaining new habits and providing individual support.

In the usual practice group diet and exercise advice was provided during four individual sessions over an eight-week period, plus two follow-up sessions. “Exercise on prescription” referrals were also available.

Twice as many adults were allocated to the WAP (221) than usual practice (109).

What did it find?

  • The WAP group lost on average 4.2kg at 12-months compared to 2.3kg in the usual practice group (mean difference 1.9kg, 95% confidence interval ‑3.7kg to ‑0.1kg).
  • At 12 months, 41% of WAP participants (61/149) had lost at least 5% of their starting body weight compared to 27% (22/83) of those receiving usual practice.
  • Dropout rates were higher in the usual care group – 31% did not complete more than half of the sessions compared to 21% of the WAP group.
  • A cost-effectiveness analysis estimated total costs, per participant, to be £195 for WAP and £176 for the nurse-led intervention. This led to an ICER of £7,742 per quality-adjusted life year gain for WAP over the usual practice, which is within the NHS willingness-to-pay thresholds.

What does current guidance say on this issue?

NICE obesity guidance from 2014 recommends multicomponent interventions as the treatment of choice. These interventions aim to increase activity levels and improve diet quality, eating behaviour and decrease calorie intake.

The NICE weight management for lifestyle services guidance from 2014 recommends an integrated approach to preventing and managing obesity. Many of the recommendations are aimed at raising awareness of services available, both to health professionals and the local population. NICE also recommend that contracted services include specific outcomes such as at least 30% of participants lose at least 5% of their baseline weight and address local needs.

What are the implications?

This study highlights the challenge in finding effective ways to achieve the behaviour change required to induce weight loss. Though the average weight loss was modest in both groups, it is encouraging that 41% of people in the WAP group lost at least 5% of their body weight, which should have health benefits.

It is not certain whether this information, gathered in a London inner city study, is applicable nationally but this WAP is may be a reasonable candidate for consideration when developing local weight management services. Setting up costs would need to include training of the healthcare professionals delivering the service, which in this case took two days.

Recruitment and attendance in such interventions remains a challenge.

Citation and Funding

McRobbie H, Hajek P, Peerbux S, et al. Tackling obesity in areas of high social deprivation: clinical effectiveness and cost-effectiveness of a task-based weight management group programme - a randomised controlled trial and economic evaluation. Health Technol Assess. 2016;20(79):1-150.

This project was funded by the National Institute for Health Research Health Technology Assessment programme as project number 09/127/34.

Bibliography

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

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

NIHR Dissemination Centre. Themed Review: On the level: evidence for action on type 2 diabetes. Southampton: National Institute for Health Research; 2016.

Public Health England.  Patterns and trends in adult obesity [slide set]. London: Public Health England; 2016.

Public Health England. Making the case for tackling obesity – why invest? [slide set]. London: Public Health England; 2015.

Why was this study needed?

Costs of treating obesity and associated health conditions continue to rise. Public Health England estimates that one in four adults is obese (BMI ≥ 30kg/m2), costing society £27 billion per year, including £19 billion being spent on NHS care and obesity medications. Obesity is very prevalent in black and minority ethnic groups, especially amongst women, and the highest rates of obesity are found in those with the lowest level of income and in the most deprived areas.

Many approaches have been tried in primary care for reducing obesity but at best weight loss tends to be modest and weight is often regained after the intervention stops. Intensive behavioural approaches may help but require a lot of input from staff and commitment from participants.

This trial aimed to evaluate the long-term effects of a group based weight management plan involving weekly tasks and tools to lose weight and then maintain a healthier weight.

What did this study do?

This randomised controlled trial compared a group Weight Action Programme (WAP) with usual practice delivered by a nurse. The trial recruited 330 adults, 72% female, with a BMI between 30kg/m2 to 45kg/m2 from six boroughs in London.

The WAP involved eight weekly group sessions on self-regulation (e.g. food diaries), motivational techniques (e.g. incremental targets), a peer support network, and dietary and exercise advice and monitoring by pedometer. Ten monthly sessions then focussed on maintaining new habits and providing individual support.

In the usual practice group diet and exercise advice was provided during four individual sessions over an eight-week period, plus two follow-up sessions. “Exercise on prescription” referrals were also available.

Twice as many adults were allocated to the WAP (221) than usual practice (109).

What did it find?

  • The WAP group lost on average 4.2kg at 12-months compared to 2.3kg in the usual practice group (mean difference 1.9kg, 95% confidence interval ‑3.7kg to ‑0.1kg).
  • At 12 months, 41% of WAP participants (61/149) had lost at least 5% of their starting body weight compared to 27% (22/83) of those receiving usual practice.
  • Dropout rates were higher in the usual care group – 31% did not complete more than half of the sessions compared to 21% of the WAP group.
  • A cost-effectiveness analysis estimated total costs, per participant, to be £195 for WAP and £176 for the nurse-led intervention. This led to an ICER of £7,742 per quality-adjusted life year gain for WAP over the usual practice, which is within the NHS willingness-to-pay thresholds.

What does current guidance say on this issue?

NICE obesity guidance from 2014 recommends multicomponent interventions as the treatment of choice. These interventions aim to increase activity levels and improve diet quality, eating behaviour and decrease calorie intake.

The NICE weight management for lifestyle services guidance from 2014 recommends an integrated approach to preventing and managing obesity. Many of the recommendations are aimed at raising awareness of services available, both to health professionals and the local population. NICE also recommend that contracted services include specific outcomes such as at least 30% of participants lose at least 5% of their baseline weight and address local needs.

What are the implications?

This study highlights the challenge in finding effective ways to achieve the behaviour change required to induce weight loss. Though the average weight loss was modest in both groups, it is encouraging that 41% of people in the WAP group lost at least 5% of their body weight, which should have health benefits.

It is not certain whether this information, gathered in a London inner city study, is applicable nationally but this WAP is may be a reasonable candidate for consideration when developing local weight management services. Setting up costs would need to include training of the healthcare professionals delivering the service, which in this case took two days.

Recruitment and attendance in such interventions remains a challenge.

Citation and Funding

McRobbie H, Hajek P, Peerbux S, et al. Tackling obesity in areas of high social deprivation: clinical effectiveness and cost-effectiveness of a task-based weight management group programme - a randomised controlled trial and economic evaluation. Health Technol Assess. 2016;20(79):1-150.

This project was funded by the National Institute for Health Research Health Technology Assessment programme as project number 09/127/34.

Bibliography

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

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

NIHR Dissemination Centre. Themed Review: On the level: evidence for action on type 2 diabetes. Southampton: National Institute for Health Research; 2016.

Public Health England.  Patterns and trends in adult obesity [slide set]. London: Public Health England; 2016.

Public Health England. Making the case for tackling obesity – why invest? [slide set]. London: Public Health England; 2015.

Tackling obesity in areas of high social deprivation: clinical effectiveness and cost-effectiveness of a task-based weight management group programme a randomised controlled trial and economic evaluation

Published on 1 November 2016

McRobbie H, Hajek P, Peerbux S, Kahan BC, Eldridge S, Trépel D, Parrott S, Griffiths C, Snuggs S, Myers Smith K.

Health Technology Assessment Volume 20 Issue 80 , 2016

Background An increasing number of people require help to manage their weight. The NHS recommends weight loss advice by general practitioners and/or a referral to a practice nurse. Although this is helpful for some, more effective approaches that can be disseminated economically on a large scale are needed. Objective To assess whether or not a task-based weight management programme [Weight Action Programme (WAP)] has better long-term effects than a ‘best practice’ intervention provided in primary care by practice nurses. Design Randomised controlled trial with cost-effectiveness analysis. Setting General practices in east London, UK. Participants Three hundred and thirty adults with a body mass index (BMI) of ≥ 30 kg/m2 or a BMI of ≥ 28 kg/m2 plus comorbidities were recruited from local general practices and via media publicity. Those who had a BMI of > 45 kg/m2, had lost > 5% of their body weight in the previous 6 months, were currently pregnant or taking psychiatric medications were excluded. Participants were randomised (2 : 1) to the WAP or nurse arms. Interventions The WAP intervention was delivered in eight weekly group sessions that combined dietary and physical activity, advice and self-monitoring in a group-oriented intervention. The initial course was followed by 10 monthly group maintenance sessions open to all participants in this study arm. The practice nurse intervention (best usual care) consisted of four one-to-one sessions delivered over 8 weeks, and included standard advice on diet and physical activity based on NHS ‘Change4Life’ materials and motivational support. Main outcome measures The primary outcome measure was weight change at 12 months. Secondary outcome measures included change in BMI, waist circumference and blood pressure, and proportion of participants losing at least 5% and 10% of baseline body weight. Staff collecting measurements at the 6- and 12-month follow-ups were blinded to treatment allocation. The primary outcome measure was analysed according to the intention-to-treat principle, and included all participants with at least one recorded outcome at either 1, 2, 6 or 12 months. The analysis employed a mixed-effects linear regression model, adjusted for baseline weight, age, sex, ethnicity, smoking status and general practice. The European Quality of Life-5 Dimensions-5 Levels questionnaire was completed and used to estimate quality-adjusted life-years (QALYs) within the cost-effectiveness analysis. Results There were 330 participants (WAP arm, n = 221; nurse arm, n = 109; 72% women). A total of 291 (88%) participants (WAP arm, n = 194; nurse arm, n = 97) were included in the main analysis for the primary outcome. Weight loss at 12 months was greater in the WAP arm than in the nurse intervention arm [–4.2 kg vs. –2.3 kg; difference –1.9 kg, 95% confidence interval (CI) –3.7 to –0.1 kg; p = 0.04]. Participants in the WAP arm were more likely than participants in the nurse arm to have lost at least 5% of their baseline body weight at 12 months (41% vs. 27%; odds ratio 14.61, 95% CI 2.32 to 91.96; p = 0.004). The incremental cost-effectiveness ratio for WAP over and above the nurse arm is £7742 per QALY. Conclusions A WAP delivered in general practice better promotes weight loss over 12 months than a best usual practice nurse-led weight loss programme. Limitations The trial recruited mostly women. Research is needed into factors that would make weight loss programmes more attractive to men. 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. 20, No. 79. See the NIHR Journals Library website for further project information.

Body mass index (BMI) is a measure of weight relative to height. BMI is divided into sub-groups as follows:

  • normal weight: 18.5 to 24.9 kg/m2
  • overweight: 25.0 to 29.9
  • simple obesity: 30.0 to 34.9
  • severe obesity: 35.0 to 35.9
  • morbid obesity: 40.0 to 44.9
  • super obesity: 45.0 or greater

Multicomponent interventions use a variety of tools and techniques to address different aspects of a disease. For example, obesity is a complex disease that often requires changes to diet, activity levels, and behavioural thinking. A multicomponent intervention would use appropriate tools and techniques (e.g. Cognitive Behavioural Therapy, goal setting, dietary and exercise advice) to address these.

Expert commentary

Obesity has significant impact on people, the society, the economy and the NHS. Obesity is a risk factor for type 2 diabetes, hypertension, cancer and cardiovascular disease. However, even 5% loss of body weight can have favourable impact on obesity-related comorbidities. Life-style interventions result in successful short-term weight loss, but long-term maintenance remains challenging.

This is partly because many interventions are of short duration. Considering the chronic nature of obesity, short-term interventions should not be expected to result in long-term benefits. In any chronic condition, such as hypertension, stopping treatment results in worsening of the disease and obesity is no different. Hence, to tackle obesity prolonged interventions are needed. It might be time to consider lifelong treatments for obesity.

Dr Abd A Tahrani, NIHR Clinician Scientist, University of Birmingham; Honorary Consultant Physician in Diabetes and Endocrinology, Birmingham Heartlands Hospital; Lead Medical Weight Management - Research and Diabetic Neuropath Services, University of Birmingham

Tools

Categories

  •   Public Health, Obesity and nutrition, Primary care