NIHR Signal 52-week programme leads to more weight loss than 12-week

Published on 12 September 2017

Obese people referred to a 52-week group weight management programme lost about 2kg more weight on average by one and two years compared to those referred for the standard 12 weeks. These modest health gains were also more likely to be sustained over time in the long programme. A brief intervention led to 3kg weight loss at 12 months, but the 12- and 52-week more intensive programmes led to 23% and 46% more weight loss respectively.

The number of people who are obese or overweight continues to rise in the UK. It is challenging for people to both lose weight and maintain that weight loss.

GPs can refer people to NHS-funded group weight management programmes. Normally, referrals are for 12 weeks of sessions. This UK trial of 23 practices compared 12- and 52-week programmes with a brief information-only intervention.

Although short-term costs are higher, referring people to a 52-week programme is probably more cost-effective regarding long term disease prevention than the current 12-week model.

52-week programme leads to more weight loss than 12-week

Share your views on the research.

Why was this study needed?

Over half of adults in the UK are considered overweight or obese. Obesity is associated with many chronic health conditions such as diabetes and cardiovascular disease.

There are a large number of approaches that people can take to reduce their weight. The first challenge is losing weight, but people can find it difficult to keep off the weight that they have lost.

NICE recommends that GPs refer obese people (and overweight if there is capacity) to lifestyle weight management programmes that last for at least three months. To date, studies have compared different programmes but not directly looked at whether longer programmes may offer better results.

This trial investigated whether referring people to a longer programme of 52 weeks was more effective in helping people to lose weight and maintain weight loss, compared to the standard 12 weeks. People were followed up for two years.

What did this study do?

This randomised controlled trial recruited overweight to obese adults (body mass index 28kg/m2 or higher) from 23 general practices in England. Exclusions included current participation in a weight loss programme, prior or planned weight loss (bariatric) surgery, pregnancy, the presence of an eating disorder or special communication needs.

The 1,267 participants were randomised in a 2:5:5 ratio to a brief intervention (self-help weight management booklet), referral to a group weight management programme for 12- or 52-weeks. The programme included weekly meetings with weigh-ins, group discussion and information support (such as recipe books).

Average participant age was 53 years, average BMI 34.5 kg/m2 and 68% were female. Around 65% of all participants completed assessments at one and two years, but all randomised participants were included in the intention-to-treat analysis. By necessity, participants and research staff were aware of the allocated intervention. The results of this high-quality trial involving NHS general practices will be relevant to UK practice.

What did it find?

  • The 52-week weight management programme helped people to lose more weight by one year (‑6.76kg) compared to the 12-week programme (‑4.75kg) or brief intervention (‑3.26kg). By two years, participants in all groups had regained some weight, but weight loss since the start of the trial was still significantly different between groups: 52-weeks ‑4.29kg; 12-weeks ‑3.00kg; and brief intervention ‑2.30kg.
  • Participants receiving either the 12- or 52-week programme were more likely to have lost 5% of their body weight by one year (42% and 57%, respectively) compared to the brief intervention (25%). By two years fewer people had maintained 5% loss, but both programmes were still more effective than the brief intervention (22%), and the 52-week programme (39%) remained better than the 12-week (27%).
  • The 52-week programme also gave greater improvements in waist circumference and blood sugar control compared with the brief intervention and 12-week programme.
  • The 52-week programme was more expensive (£195) than the 12-week programme (£60) and the brief intervention (£18.50). The extra cost over one year was £26 per kg for the 12-week programme and £75 per kg for the 52-week.
  • Using a 25-year timeframe, the 52-week programme was estimated to be cost-effective compared to the brief intervention (£2,493 per quality-adjusted life year [QALY] gained) and compared to the 12-week programme (£3,804 per QALY). The 52-week programme was estimated to save £8.61 million in direct health care costs compared with the 12-week programme, at the cost of £4.9 million per 100,000 people.

What does current guidance say on this issue?

NICE guidelines recommend that people who are obese (with a BMI over 30 kg/m2) should be referred to group lifestyle weight management services. Where possible, overweight people with a BMI of 25 to 30 kg/m2 should also be referred.

Thresholds for both overweight and obesity may be lowered for people from black and ethnic minority groups, and those with other risk factors, such as type 2 diabetes.

NICE advises that programmes should be multicomponent, addressing diet, activity and behaviour change. Programmes should last for at least 12 weeks, with sessions at least weekly or fortnightly.

What are the implications?

This trial supports current NICE recommendations to refer people to lifestyle weight management programmes to support weight loss.

Most funded referrals are currently for 12-week programmes. This trial suggests that referring people to a 52-week programme may lead to more sustainable weight loss and be a better use of NHS resources.

Local commissioners may want to consider commissioning 52-week programmes to realise greater long-term clinical and cost benefits.

Citation and Funding

Ahern AL, Wheeler GM, Aveyard P, et al. Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial. Lancet. 2017;389(10085):2214-25.

Funded by the National Prevention Research Initiative, Weight Watchers International (as part of a UK Medical Research Council Industrial Collaboration Award).

Bibliography

Brindal, E. Weight management programmes of extended duration. Lancet. 2017;389(10085):2168-70.

NHS Choices. Obesity. London: Department of Health; 2016.

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

Office for National Statistics. Statistics on obesity, activity and diet: England 2017. Newport: Office for National Statistics; 2017.

PHE. National mapping of weight management services: provision of tier 2 and tier 3 services in England. London: Public Health England; 2015.

Why was this study needed?

Over half of adults in the UK are considered overweight or obese. Obesity is associated with many chronic health conditions such as diabetes and cardiovascular disease.

There are a large number of approaches that people can take to reduce their weight. The first challenge is losing weight, but people can find it difficult to keep off the weight that they have lost.

NICE recommends that GPs refer obese people (and overweight if there is capacity) to lifestyle weight management programmes that last for at least three months. To date, studies have compared different programmes but not directly looked at whether longer programmes may offer better results.

This trial investigated whether referring people to a longer programme of 52 weeks was more effective in helping people to lose weight and maintain weight loss, compared to the standard 12 weeks. People were followed up for two years.

What did this study do?

This randomised controlled trial recruited overweight to obese adults (body mass index 28kg/m2 or higher) from 23 general practices in England. Exclusions included current participation in a weight loss programme, prior or planned weight loss (bariatric) surgery, pregnancy, the presence of an eating disorder or special communication needs.

The 1,267 participants were randomised in a 2:5:5 ratio to a brief intervention (self-help weight management booklet), referral to a group weight management programme for 12- or 52-weeks. The programme included weekly meetings with weigh-ins, group discussion and information support (such as recipe books).

Average participant age was 53 years, average BMI 34.5 kg/m2 and 68% were female. Around 65% of all participants completed assessments at one and two years, but all randomised participants were included in the intention-to-treat analysis. By necessity, participants and research staff were aware of the allocated intervention. The results of this high-quality trial involving NHS general practices will be relevant to UK practice.

What did it find?

  • The 52-week weight management programme helped people to lose more weight by one year (‑6.76kg) compared to the 12-week programme (‑4.75kg) or brief intervention (‑3.26kg). By two years, participants in all groups had regained some weight, but weight loss since the start of the trial was still significantly different between groups: 52-weeks ‑4.29kg; 12-weeks ‑3.00kg; and brief intervention ‑2.30kg.
  • Participants receiving either the 12- or 52-week programme were more likely to have lost 5% of their body weight by one year (42% and 57%, respectively) compared to the brief intervention (25%). By two years fewer people had maintained 5% loss, but both programmes were still more effective than the brief intervention (22%), and the 52-week programme (39%) remained better than the 12-week (27%).
  • The 52-week programme also gave greater improvements in waist circumference and blood sugar control compared with the brief intervention and 12-week programme.
  • The 52-week programme was more expensive (£195) than the 12-week programme (£60) and the brief intervention (£18.50). The extra cost over one year was £26 per kg for the 12-week programme and £75 per kg for the 52-week.
  • Using a 25-year timeframe, the 52-week programme was estimated to be cost-effective compared to the brief intervention (£2,493 per quality-adjusted life year [QALY] gained) and compared to the 12-week programme (£3,804 per QALY). The 52-week programme was estimated to save £8.61 million in direct health care costs compared with the 12-week programme, at the cost of £4.9 million per 100,000 people.

What does current guidance say on this issue?

NICE guidelines recommend that people who are obese (with a BMI over 30 kg/m2) should be referred to group lifestyle weight management services. Where possible, overweight people with a BMI of 25 to 30 kg/m2 should also be referred.

Thresholds for both overweight and obesity may be lowered for people from black and ethnic minority groups, and those with other risk factors, such as type 2 diabetes.

NICE advises that programmes should be multicomponent, addressing diet, activity and behaviour change. Programmes should last for at least 12 weeks, with sessions at least weekly or fortnightly.

What are the implications?

This trial supports current NICE recommendations to refer people to lifestyle weight management programmes to support weight loss.

Most funded referrals are currently for 12-week programmes. This trial suggests that referring people to a 52-week programme may lead to more sustainable weight loss and be a better use of NHS resources.

Local commissioners may want to consider commissioning 52-week programmes to realise greater long-term clinical and cost benefits.

Citation and Funding

Ahern AL, Wheeler GM, Aveyard P, et al. Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial. Lancet. 2017;389(10085):2214-25.

Funded by the National Prevention Research Initiative, Weight Watchers International (as part of a UK Medical Research Council Industrial Collaboration Award).

Bibliography

Brindal, E. Weight management programmes of extended duration. Lancet. 2017;389(10085):2168-70.

NHS Choices. Obesity. London: Department of Health; 2016.

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

Office for National Statistics. Statistics on obesity, activity and diet: England 2017. Newport: Office for National Statistics; 2017.

PHE. National mapping of weight management services: provision of tier 2 and tier 3 services in England. London: Public Health England; 2015.

Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial

Published on 10 May 2017

Ahern, A. L.,Wheeler, G. M.,Aveyard, P.,Boyland, E. J.,Halford, J. C. G.,Mander, A. P.,Woolston, J.,Thomson, A. M.,Tsiountsioura, M.,Cole, D.,Mead, B. R.,Irvine, L.,Turner, D.,Suhrcke, M.,Pimpin, L.,Retat, L.,Jaccard, A.,Webber, L.,Cohn, S. R.,Jebb, S. A.

Lancet , 2017

BACKGROUND: Evidence exist that primary care referral to an open-group behavioural programme is an effective strategy for management of obesity, but little evidence on optimal intervention duration is available. We aimed to establish whether 52-week referral to an open-group weight-management programme would achieve greater weight loss and improvements in a range of health outcomes and be more cost-effective than the current practice of 12-week referrals. METHODS: In this non-blinded, parallel-group, randomised controlled trial, we recruited participants who were aged 18 years or older and had body-mass index (BMI) of 28 kg/m2 or higher from 23 primary care practices in England. Participants were randomly assigned (2:5:5) to brief advice and self-help materials, a weight-management programme (Weight Watchers) for 12 weeks, or the same weight-management programme for 52 weeks. We followed-up participants over 2 years. The primary outcome was weight at 1 year of follow-up, analysed with mixed-effects models according to intention-to-treat principles and adjusted for centre and baseline weight. In a hierarchical closed-testing procedure, we compared combined behavioural programme arms with brief intervention, then compared the 12-week programme and 52-week programme. We did a within-trial cost-effectiveness analysis using person-level data and modelled outcomes over a 25-year time horizon using microsimulation. This study is registered with Current Controlled Trials, number ISRCTN82857232. FINDINGS: Between Oct 18, 2012, and Feb 10, 2014, we enrolled 1269 participants. 1267 eligible participants were randomly assigned to the brief intervention (n=211), the 12-week programme (n=528), and the 52-week programme (n=528). Two participants in the 12-week programme had been found to be ineligible shortly after randomisation and were excluded from the analysis. 823 (65%) of 1267 participants completed an assessment at 1 year and 856 (68%) participants at 2 years. All eligible participants were included in the analyses. At 1 year, mean weight changes in the groups were -3.26 kg (brief intervention), -4.75 kg (12-week programme), and -6.76 kg (52-week programme). Participants in the behavioural programme lost more weight than those in the brief intervention (adjusted difference -2.71 kg, 95% CI -3.86 to -1.55; p<0.0001). The 52-week programme was more effective than the 12-week programme (-2.14 kg, -3.05 to -1.22; p<0.0001). Differences between groups were still significant at 2 years. No adverse events related to the intervention were reported. Over 2 years, the incremental cost-effectiveness ratio (ICER; compared with brief intervention) was pound159 per kg lost for the 52-week programme and pound91 per kg for the 12-week programme. Modelled over 25 years after baseline, the ICER for the 12-week programme was dominant compared with the brief intervention. The ICER for the 52-week programme was cost-effective compared with the brief intervention ( pound2394 per quality-adjusted life-year [QALY]) and the 12-week programme ( pound3804 per QALY). INTERPRETATION: For 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. FUNDING: National Prevention Research Initiative, Weight Watchers International (as part of an UK Medical Research Council Industrial Collaboration Award).

Expert commentary

Obesity is a chronic, relapsing disease and therefore requires lifelong management. Most weight loss programmes offered by the NHS are short-term (often only 12 weeks in duration).

This study shows that although a 12-week weight loss programme for overweight and obese people is a little better than a brief intervention, a 52-week intervention gave more sustained weight loss and was associated with significant improvements in cardiovascular risk factors, measures of glycaemia and was cost-effective.

Cheaper short-term weight loss programmes offer false economy for treating the lifelong condition of obesity.

John Wilding, Professor of Medicine & Honorary Consultant Physician, University Hospital Aintree

Categories

  •   Obesity and nutrition, Primary care