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Study Overview
Objective. To compare weight loss among patients using self-directed methods vs. those participating in a multi-component Weight Watchers (WW) program where participants could access content in person, online, or using mobile applications.
Study design. Randomized trial funded by Weight Watchers International.
Setting and participants. A market research firm was used to identify potentially eligible persons in a Northeastern U.S. metro area. Of those who responded to emails describing the project (n = 336), 292 were deemed eligible based on having a body mass index (BMI) between 27 and 40 kg/m2, not currently being on a diet or taking weight-loss medications, and not reporting any medical conditions that could interfere with their participation in a weight loss program (eg, thyroid disease, cardiac disease, pregnancy, cancer).
Eligible participants who consented were computer randomized to 1 of 2 arms. The intervention arm participants were provided with free access to the WW program, and those in the control group received only informational materials. The WW program consisted of putting participants on a food and physical activity plan and providing them with group support, as well as teaching them skills to help promote behavior change in a series of 24 weekly in-person meetings. In addition to in-person meetings, information and support could be accessed online and using mobile devices that allowed the formation of an online community with message board capabilities. Participants were followed for a 24-week period with weigh-ins at baseline and 3 and 6 months.
Main outcome measures. The primary outcomes in this study were the difference between the groups in BMI or weight at 3 and 6 months. BMI was measured at in-person study visits. Repeated-measures ANOVA was used to compare the groups, both on persons who completed the trial and also with an intention-to-treat sub-analysis where the last available measure was carried forward to the 6-month mark for those who were lost to follow-up.
Secondary outcomes included evaluation of the impact of mode (in person, online, or mobile device) and frequency of access of the WW program on BMI change. Participants were categorized as having high attendance if they came to more than 50% of the in-person sessions, or low attendance if they came to fewer. They were categorized as frequent or infrequent users of the web or mobile interfaces dichotomized around self-reported use of at least 2 times per week. One-way ANOVA was used to compare weight losses according to the type and frequency of access amongst WW participants. Logistic regression was used to evaluate the impact of the exposure of high vs. low attendance on dichotomized weight loss outcomes at the 5% and 10% level.
Results. There were no significant differences between the WW (n = 147) and self-help (n = 145) arms with respect to baseline characteristics. The sample was predominantly female (89.8%), middle aged (mean (SD) 46.5 (10.5) yr), and white (90.7%). The mean BMI at baseline was in the class I (BMI ≥ 30 but < 35) obesity category (mean (SD) 33.0 (3.6) kg/m2). Of the total sample of 292 initial participants, 257 (88%) completed the 6-month trial.
Both primary and intention-to-treat analyses revealed a greater degree of weight loss (or BMI reduction) among WW versus self-help participants. Specifically, the WW participants lost a mean of 4.6 kg at 6 months, and the self-help participants lost a mean of 0.6 kg. When the outcome was dichotomized around probability of achieving at least a 5% or 10% weight loss, WW participants were far more likely to achieve both outcomes (5% loss: odds ratio [OR] 8.0, 95% CI 3.9-16.2; 10% loss: OR 8.8, 95% CI 3.0-25.9). The most rapid weight loss period for WW participants was clearly in the first 3 months of the trial, after which weight loss slowed considerably.
Among the WW participants, when individuals were compared according to how many modes of access they used (0, 1, 2 or 3), participants using all 3 modes had significantly greater weight loss (P < 0.01) than all others. Mean weight loss was approximately equal between persons who used 1 or 2 modes of access. Overall weight loss at 6 months varied from a mean of 2 kg in the “0 components group” to approximately 4.5 kg in the 1 or 2 components group, to almost 10 kg in the 3 components group. Frequency of contact (in person or electronically) also corresponded to the amount of weight lost.
On average, the WW group attended fewer than 50% of the available 24 weekly sessions (mean (sd) 9.1 (7.3) sessions attended). However, those who came to at least 12 sessions were far more likely to achieve 5% and/or 10% weight losses than those who attended fewer sessions (5% loss: OR 11.2, 95% CI 4.6-26.9; 10% loss: OR 15.5, 95% CI 5.6-43.2). Frequent (vs. less frequent) use of the online website and mobile devices were also associated with statistically significant improvements in weight loss; however, the magnitude of effect for these modalities was much smaller than for the frequency of in person visits. Frequent website users, for example, had an OR of 3.1 (95% CI 1.5-6.5) for achieving a 5% weight loss compared with less frequent users, and frequent mobile app users had an OR of 2.0 (95% CI 1.0-4.1) for achieving that 5% loss compared with nonfrequent users. Stepwise regression models supported this pattern, indicating that the greatest predictor of weight loss was attendance at in-person meetings, accounting for 29.4% of the variance in 6-month weight losses.
Conclusion. Participants randomized to participate in a commercially available weight loss program with access to in-person, online, and mobile support lost significantly more weight than those who attempted to lose weight via self-help.
Commentary
With the prevalence of obesity in the United States now exceeding 30% [1], primary care physicians are routinely asked to counsel patients on the dangers of excess weight or to provide advice on how best to lose weight. In light of time demands, lack of expertise in weight loss management, and, historically, lack of reimbursement for obesity-specific care, primary care practices have not traditionally been ideal locations for provision of weight management services [2]. Behavioral approaches to weight loss require relatively high-frequency contact for a period of at least several months in order to provide the greatest chance of patients successfully losing weight [3]. In fact, many behavior change programs are modeled after the Diabetes Prevention Program, which relied on 24 weekly face-to-face visits (followed by every other week visits) in order for participants to achieve even modest weight losses (5%-10% of starting weight) [4]. To integrate such a program into most primary care practices has not been widely feasible, however. For physicians practicing in large academic centers, there may be specialized weight clinics where patients can be referred to receive such care, but for most community physicians and those practicing in smaller organizations, finding the right place to refer patients interested in weight loss via diet and exercise can be difficult. As a result of this and other factors, many patients elect to self-manage their own weight loss attempts with limited success.
One option for primary care physicians who do not feel comfortable or able to oversee the behavioral weight loss attempts of their patients is to consider referral to a commercial weight loss program, such as the one examined in this study. There are several such programs throughout the United States, and, as pointed out by these authors, the WW program itself has funded previous research studies, including one randomized trial that showed modestly superior weight loss outcomes amongst its participants, as compared to self-directed therapy [5]. A 2005 systematic review of commercially available weight loss programs concluded that there was limited evidence to support the use of such programs, particularly those that were internet-based [6]. The current study builds upon existing work by evaluating the impact of the newer, 3-modality (in-person, online, and mobile) WW intervention. Such an evaluation is important given the present-day near ubiquity of smartphone and internet access for most middle-aged US adults.
This randomized controlled trial tested this newer-modality WW program against self-directed behavioral weight loss therapy and found that participants achieved greater weight loss with the WW program. The randomized design was a strength of the study, as was the use of intention-to-treat analysis (although loss to follow-up was relatively minimal). The findings of improved weight loss amongst WW participants are not novel, however, they underscore that this program is a viable option for patients who are financially able (and motivated) to commit to such an endeavor. In terms of evaluating the added value of internet-based and mobile applications to the traditional in-person visit, although the authors note that participants who used all 3 modalities lost the most weight, it was in-person visit attendance that accounted for the greatest share of weight loss success. Thus, the internet and mobile app access methods ought not be considered as replacements for the in-person visits but rather as supplements, which does not support their use as an alternative for busy people who don’t have time to participate in person. Additionally, as noted by the authors in their discussion section, the number of components accessed by participants could merely be a marker for level of motivation—thus it was higher motivation levels perhaps driving the weight loss, rather than an additive effect of the 3 modalities. Because motivation to change was not assessed in this study, it is difficult to know what role this factor played in weight loss for the WW participants.
Unfortunately, the trial did not follow participants past the end of the intervention period to determine whether the weight changes were maintained once WW participation was complete. At least 1 prior study evaluating this program, however, showed that despite some weight regain, participants in this commercial program do maintain a larger degree of weight loss than their self-management counterparts at up to 2 years after randomization [6].
The generalizability of these study findings may be somewhat limited based on the demographics of trial participants. Nearly all of them were non-Hispanic white women, which is not too surprising given the nature of the intervention. It does raise an important question, however, about whether similar programs are available for (or of interest to) male and/or non-white patients. While it is possible that the geographic area they sampled from for the study was simply predominated by non-Hispanic white residents, no data were provided about the sampling pool, so one can only assume a somewhat biased response based on the nature of the intervention. Additionally, the patients in this study were, on average, class I obesity patients and lost only a moderate amount of weight. Furthermore, medically complex persons were excluded from participating. Providers caring for patients with more severe degrees of obesity and/or those who have multiple poorly controlled medical conditions should carefully consider whether such patients are appropriate for commercial programs before referring them, and should calibrate their patients’ expectations of the degree and durability of weight loss that will be obtained through such programs.
The participants in this trial received the WW intervention free of charge, which would obviously not be the case for real-world patients enrolling in commercial weight loss programs. Cost, therefore, might be an important barrier to assess prior to referring any patients to such programs. However, the idea of paying for the intervention might paradoxically improve outcomes—the concept of having “skin in the game,” or feeling more compelled to participate in something you have paid for, a popular concept in behavioral economics, could come into play in this context. Paying for WW might “frame” the service as desirable, making people more likely to attend, as opposed to essentially being paid to do it (as in this study), which might have framed it more as a chore, or something undesirable [7].
Finally, given the possible upcoming shift in provider reimbursement for obesity-related counseling heralded by 2012 Centers for Medicare and Medicaid coverage changes [8], providers may become increasingly comfortable managing their patients’ weight loss attempts in the primary care setting, decreasing the need for outsourcing to commercial programs in the near future.
Applications for Clinical Practice
Commercial weight loss programs with combined modalities of in-person, online, and mobile support can provide an alternative to self-directed weight loss, particularly for patients in the demographic groups targeted by such programs. Clinicians who do not feel able to provide such care in the clinical context, or who do not have referral access to clinical weight loss programs might consider referral to commercial programs for some patients. Appropriate selection of patients is important, however, and physicians should consider factors such as financial means, desired amount of weight loss, and medical complexity before recommending such a program. Furthermore, the evidence surrounding long-term maintenance of weight loss after participation in such programs is weak.
—Kristina Lewis, MD, MPH
1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307:491–7.
2. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J Gen Intern Med 2009;24:1073–9.
3. Butryn ML, Webb V, Wadden TA. Behavioral treatment of obesity. Psychiatr Clin North Am 2011;34:841–59.
4. DPP Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.
5. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289:1792–8.
6. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med 2005;142:56–66.
7. Zimmerman FJ. Using behavioral economics to promote physical activity. Prev Med 2009;49:289–91.
8. Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity. 2012.
Study Overview
Objective. To compare weight loss among patients using self-directed methods vs. those participating in a multi-component Weight Watchers (WW) program where participants could access content in person, online, or using mobile applications.
Study design. Randomized trial funded by Weight Watchers International.
Setting and participants. A market research firm was used to identify potentially eligible persons in a Northeastern U.S. metro area. Of those who responded to emails describing the project (n = 336), 292 were deemed eligible based on having a body mass index (BMI) between 27 and 40 kg/m2, not currently being on a diet or taking weight-loss medications, and not reporting any medical conditions that could interfere with their participation in a weight loss program (eg, thyroid disease, cardiac disease, pregnancy, cancer).
Eligible participants who consented were computer randomized to 1 of 2 arms. The intervention arm participants were provided with free access to the WW program, and those in the control group received only informational materials. The WW program consisted of putting participants on a food and physical activity plan and providing them with group support, as well as teaching them skills to help promote behavior change in a series of 24 weekly in-person meetings. In addition to in-person meetings, information and support could be accessed online and using mobile devices that allowed the formation of an online community with message board capabilities. Participants were followed for a 24-week period with weigh-ins at baseline and 3 and 6 months.
Main outcome measures. The primary outcomes in this study were the difference between the groups in BMI or weight at 3 and 6 months. BMI was measured at in-person study visits. Repeated-measures ANOVA was used to compare the groups, both on persons who completed the trial and also with an intention-to-treat sub-analysis where the last available measure was carried forward to the 6-month mark for those who were lost to follow-up.
Secondary outcomes included evaluation of the impact of mode (in person, online, or mobile device) and frequency of access of the WW program on BMI change. Participants were categorized as having high attendance if they came to more than 50% of the in-person sessions, or low attendance if they came to fewer. They were categorized as frequent or infrequent users of the web or mobile interfaces dichotomized around self-reported use of at least 2 times per week. One-way ANOVA was used to compare weight losses according to the type and frequency of access amongst WW participants. Logistic regression was used to evaluate the impact of the exposure of high vs. low attendance on dichotomized weight loss outcomes at the 5% and 10% level.
Results. There were no significant differences between the WW (n = 147) and self-help (n = 145) arms with respect to baseline characteristics. The sample was predominantly female (89.8%), middle aged (mean (SD) 46.5 (10.5) yr), and white (90.7%). The mean BMI at baseline was in the class I (BMI ≥ 30 but < 35) obesity category (mean (SD) 33.0 (3.6) kg/m2). Of the total sample of 292 initial participants, 257 (88%) completed the 6-month trial.
Both primary and intention-to-treat analyses revealed a greater degree of weight loss (or BMI reduction) among WW versus self-help participants. Specifically, the WW participants lost a mean of 4.6 kg at 6 months, and the self-help participants lost a mean of 0.6 kg. When the outcome was dichotomized around probability of achieving at least a 5% or 10% weight loss, WW participants were far more likely to achieve both outcomes (5% loss: odds ratio [OR] 8.0, 95% CI 3.9-16.2; 10% loss: OR 8.8, 95% CI 3.0-25.9). The most rapid weight loss period for WW participants was clearly in the first 3 months of the trial, after which weight loss slowed considerably.
Among the WW participants, when individuals were compared according to how many modes of access they used (0, 1, 2 or 3), participants using all 3 modes had significantly greater weight loss (P < 0.01) than all others. Mean weight loss was approximately equal between persons who used 1 or 2 modes of access. Overall weight loss at 6 months varied from a mean of 2 kg in the “0 components group” to approximately 4.5 kg in the 1 or 2 components group, to almost 10 kg in the 3 components group. Frequency of contact (in person or electronically) also corresponded to the amount of weight lost.
On average, the WW group attended fewer than 50% of the available 24 weekly sessions (mean (sd) 9.1 (7.3) sessions attended). However, those who came to at least 12 sessions were far more likely to achieve 5% and/or 10% weight losses than those who attended fewer sessions (5% loss: OR 11.2, 95% CI 4.6-26.9; 10% loss: OR 15.5, 95% CI 5.6-43.2). Frequent (vs. less frequent) use of the online website and mobile devices were also associated with statistically significant improvements in weight loss; however, the magnitude of effect for these modalities was much smaller than for the frequency of in person visits. Frequent website users, for example, had an OR of 3.1 (95% CI 1.5-6.5) for achieving a 5% weight loss compared with less frequent users, and frequent mobile app users had an OR of 2.0 (95% CI 1.0-4.1) for achieving that 5% loss compared with nonfrequent users. Stepwise regression models supported this pattern, indicating that the greatest predictor of weight loss was attendance at in-person meetings, accounting for 29.4% of the variance in 6-month weight losses.
Conclusion. Participants randomized to participate in a commercially available weight loss program with access to in-person, online, and mobile support lost significantly more weight than those who attempted to lose weight via self-help.
Commentary
With the prevalence of obesity in the United States now exceeding 30% [1], primary care physicians are routinely asked to counsel patients on the dangers of excess weight or to provide advice on how best to lose weight. In light of time demands, lack of expertise in weight loss management, and, historically, lack of reimbursement for obesity-specific care, primary care practices have not traditionally been ideal locations for provision of weight management services [2]. Behavioral approaches to weight loss require relatively high-frequency contact for a period of at least several months in order to provide the greatest chance of patients successfully losing weight [3]. In fact, many behavior change programs are modeled after the Diabetes Prevention Program, which relied on 24 weekly face-to-face visits (followed by every other week visits) in order for participants to achieve even modest weight losses (5%-10% of starting weight) [4]. To integrate such a program into most primary care practices has not been widely feasible, however. For physicians practicing in large academic centers, there may be specialized weight clinics where patients can be referred to receive such care, but for most community physicians and those practicing in smaller organizations, finding the right place to refer patients interested in weight loss via diet and exercise can be difficult. As a result of this and other factors, many patients elect to self-manage their own weight loss attempts with limited success.
One option for primary care physicians who do not feel comfortable or able to oversee the behavioral weight loss attempts of their patients is to consider referral to a commercial weight loss program, such as the one examined in this study. There are several such programs throughout the United States, and, as pointed out by these authors, the WW program itself has funded previous research studies, including one randomized trial that showed modestly superior weight loss outcomes amongst its participants, as compared to self-directed therapy [5]. A 2005 systematic review of commercially available weight loss programs concluded that there was limited evidence to support the use of such programs, particularly those that were internet-based [6]. The current study builds upon existing work by evaluating the impact of the newer, 3-modality (in-person, online, and mobile) WW intervention. Such an evaluation is important given the present-day near ubiquity of smartphone and internet access for most middle-aged US adults.
This randomized controlled trial tested this newer-modality WW program against self-directed behavioral weight loss therapy and found that participants achieved greater weight loss with the WW program. The randomized design was a strength of the study, as was the use of intention-to-treat analysis (although loss to follow-up was relatively minimal). The findings of improved weight loss amongst WW participants are not novel, however, they underscore that this program is a viable option for patients who are financially able (and motivated) to commit to such an endeavor. In terms of evaluating the added value of internet-based and mobile applications to the traditional in-person visit, although the authors note that participants who used all 3 modalities lost the most weight, it was in-person visit attendance that accounted for the greatest share of weight loss success. Thus, the internet and mobile app access methods ought not be considered as replacements for the in-person visits but rather as supplements, which does not support their use as an alternative for busy people who don’t have time to participate in person. Additionally, as noted by the authors in their discussion section, the number of components accessed by participants could merely be a marker for level of motivation—thus it was higher motivation levels perhaps driving the weight loss, rather than an additive effect of the 3 modalities. Because motivation to change was not assessed in this study, it is difficult to know what role this factor played in weight loss for the WW participants.
Unfortunately, the trial did not follow participants past the end of the intervention period to determine whether the weight changes were maintained once WW participation was complete. At least 1 prior study evaluating this program, however, showed that despite some weight regain, participants in this commercial program do maintain a larger degree of weight loss than their self-management counterparts at up to 2 years after randomization [6].
The generalizability of these study findings may be somewhat limited based on the demographics of trial participants. Nearly all of them were non-Hispanic white women, which is not too surprising given the nature of the intervention. It does raise an important question, however, about whether similar programs are available for (or of interest to) male and/or non-white patients. While it is possible that the geographic area they sampled from for the study was simply predominated by non-Hispanic white residents, no data were provided about the sampling pool, so one can only assume a somewhat biased response based on the nature of the intervention. Additionally, the patients in this study were, on average, class I obesity patients and lost only a moderate amount of weight. Furthermore, medically complex persons were excluded from participating. Providers caring for patients with more severe degrees of obesity and/or those who have multiple poorly controlled medical conditions should carefully consider whether such patients are appropriate for commercial programs before referring them, and should calibrate their patients’ expectations of the degree and durability of weight loss that will be obtained through such programs.
The participants in this trial received the WW intervention free of charge, which would obviously not be the case for real-world patients enrolling in commercial weight loss programs. Cost, therefore, might be an important barrier to assess prior to referring any patients to such programs. However, the idea of paying for the intervention might paradoxically improve outcomes—the concept of having “skin in the game,” or feeling more compelled to participate in something you have paid for, a popular concept in behavioral economics, could come into play in this context. Paying for WW might “frame” the service as desirable, making people more likely to attend, as opposed to essentially being paid to do it (as in this study), which might have framed it more as a chore, or something undesirable [7].
Finally, given the possible upcoming shift in provider reimbursement for obesity-related counseling heralded by 2012 Centers for Medicare and Medicaid coverage changes [8], providers may become increasingly comfortable managing their patients’ weight loss attempts in the primary care setting, decreasing the need for outsourcing to commercial programs in the near future.
Applications for Clinical Practice
Commercial weight loss programs with combined modalities of in-person, online, and mobile support can provide an alternative to self-directed weight loss, particularly for patients in the demographic groups targeted by such programs. Clinicians who do not feel able to provide such care in the clinical context, or who do not have referral access to clinical weight loss programs might consider referral to commercial programs for some patients. Appropriate selection of patients is important, however, and physicians should consider factors such as financial means, desired amount of weight loss, and medical complexity before recommending such a program. Furthermore, the evidence surrounding long-term maintenance of weight loss after participation in such programs is weak.
—Kristina Lewis, MD, MPH
Study Overview
Objective. To compare weight loss among patients using self-directed methods vs. those participating in a multi-component Weight Watchers (WW) program where participants could access content in person, online, or using mobile applications.
Study design. Randomized trial funded by Weight Watchers International.
Setting and participants. A market research firm was used to identify potentially eligible persons in a Northeastern U.S. metro area. Of those who responded to emails describing the project (n = 336), 292 were deemed eligible based on having a body mass index (BMI) between 27 and 40 kg/m2, not currently being on a diet or taking weight-loss medications, and not reporting any medical conditions that could interfere with their participation in a weight loss program (eg, thyroid disease, cardiac disease, pregnancy, cancer).
Eligible participants who consented were computer randomized to 1 of 2 arms. The intervention arm participants were provided with free access to the WW program, and those in the control group received only informational materials. The WW program consisted of putting participants on a food and physical activity plan and providing them with group support, as well as teaching them skills to help promote behavior change in a series of 24 weekly in-person meetings. In addition to in-person meetings, information and support could be accessed online and using mobile devices that allowed the formation of an online community with message board capabilities. Participants were followed for a 24-week period with weigh-ins at baseline and 3 and 6 months.
Main outcome measures. The primary outcomes in this study were the difference between the groups in BMI or weight at 3 and 6 months. BMI was measured at in-person study visits. Repeated-measures ANOVA was used to compare the groups, both on persons who completed the trial and also with an intention-to-treat sub-analysis where the last available measure was carried forward to the 6-month mark for those who were lost to follow-up.
Secondary outcomes included evaluation of the impact of mode (in person, online, or mobile device) and frequency of access of the WW program on BMI change. Participants were categorized as having high attendance if they came to more than 50% of the in-person sessions, or low attendance if they came to fewer. They were categorized as frequent or infrequent users of the web or mobile interfaces dichotomized around self-reported use of at least 2 times per week. One-way ANOVA was used to compare weight losses according to the type and frequency of access amongst WW participants. Logistic regression was used to evaluate the impact of the exposure of high vs. low attendance on dichotomized weight loss outcomes at the 5% and 10% level.
Results. There were no significant differences between the WW (n = 147) and self-help (n = 145) arms with respect to baseline characteristics. The sample was predominantly female (89.8%), middle aged (mean (SD) 46.5 (10.5) yr), and white (90.7%). The mean BMI at baseline was in the class I (BMI ≥ 30 but < 35) obesity category (mean (SD) 33.0 (3.6) kg/m2). Of the total sample of 292 initial participants, 257 (88%) completed the 6-month trial.
Both primary and intention-to-treat analyses revealed a greater degree of weight loss (or BMI reduction) among WW versus self-help participants. Specifically, the WW participants lost a mean of 4.6 kg at 6 months, and the self-help participants lost a mean of 0.6 kg. When the outcome was dichotomized around probability of achieving at least a 5% or 10% weight loss, WW participants were far more likely to achieve both outcomes (5% loss: odds ratio [OR] 8.0, 95% CI 3.9-16.2; 10% loss: OR 8.8, 95% CI 3.0-25.9). The most rapid weight loss period for WW participants was clearly in the first 3 months of the trial, after which weight loss slowed considerably.
Among the WW participants, when individuals were compared according to how many modes of access they used (0, 1, 2 or 3), participants using all 3 modes had significantly greater weight loss (P < 0.01) than all others. Mean weight loss was approximately equal between persons who used 1 or 2 modes of access. Overall weight loss at 6 months varied from a mean of 2 kg in the “0 components group” to approximately 4.5 kg in the 1 or 2 components group, to almost 10 kg in the 3 components group. Frequency of contact (in person or electronically) also corresponded to the amount of weight lost.
On average, the WW group attended fewer than 50% of the available 24 weekly sessions (mean (sd) 9.1 (7.3) sessions attended). However, those who came to at least 12 sessions were far more likely to achieve 5% and/or 10% weight losses than those who attended fewer sessions (5% loss: OR 11.2, 95% CI 4.6-26.9; 10% loss: OR 15.5, 95% CI 5.6-43.2). Frequent (vs. less frequent) use of the online website and mobile devices were also associated with statistically significant improvements in weight loss; however, the magnitude of effect for these modalities was much smaller than for the frequency of in person visits. Frequent website users, for example, had an OR of 3.1 (95% CI 1.5-6.5) for achieving a 5% weight loss compared with less frequent users, and frequent mobile app users had an OR of 2.0 (95% CI 1.0-4.1) for achieving that 5% loss compared with nonfrequent users. Stepwise regression models supported this pattern, indicating that the greatest predictor of weight loss was attendance at in-person meetings, accounting for 29.4% of the variance in 6-month weight losses.
Conclusion. Participants randomized to participate in a commercially available weight loss program with access to in-person, online, and mobile support lost significantly more weight than those who attempted to lose weight via self-help.
Commentary
With the prevalence of obesity in the United States now exceeding 30% [1], primary care physicians are routinely asked to counsel patients on the dangers of excess weight or to provide advice on how best to lose weight. In light of time demands, lack of expertise in weight loss management, and, historically, lack of reimbursement for obesity-specific care, primary care practices have not traditionally been ideal locations for provision of weight management services [2]. Behavioral approaches to weight loss require relatively high-frequency contact for a period of at least several months in order to provide the greatest chance of patients successfully losing weight [3]. In fact, many behavior change programs are modeled after the Diabetes Prevention Program, which relied on 24 weekly face-to-face visits (followed by every other week visits) in order for participants to achieve even modest weight losses (5%-10% of starting weight) [4]. To integrate such a program into most primary care practices has not been widely feasible, however. For physicians practicing in large academic centers, there may be specialized weight clinics where patients can be referred to receive such care, but for most community physicians and those practicing in smaller organizations, finding the right place to refer patients interested in weight loss via diet and exercise can be difficult. As a result of this and other factors, many patients elect to self-manage their own weight loss attempts with limited success.
One option for primary care physicians who do not feel comfortable or able to oversee the behavioral weight loss attempts of their patients is to consider referral to a commercial weight loss program, such as the one examined in this study. There are several such programs throughout the United States, and, as pointed out by these authors, the WW program itself has funded previous research studies, including one randomized trial that showed modestly superior weight loss outcomes amongst its participants, as compared to self-directed therapy [5]. A 2005 systematic review of commercially available weight loss programs concluded that there was limited evidence to support the use of such programs, particularly those that were internet-based [6]. The current study builds upon existing work by evaluating the impact of the newer, 3-modality (in-person, online, and mobile) WW intervention. Such an evaluation is important given the present-day near ubiquity of smartphone and internet access for most middle-aged US adults.
This randomized controlled trial tested this newer-modality WW program against self-directed behavioral weight loss therapy and found that participants achieved greater weight loss with the WW program. The randomized design was a strength of the study, as was the use of intention-to-treat analysis (although loss to follow-up was relatively minimal). The findings of improved weight loss amongst WW participants are not novel, however, they underscore that this program is a viable option for patients who are financially able (and motivated) to commit to such an endeavor. In terms of evaluating the added value of internet-based and mobile applications to the traditional in-person visit, although the authors note that participants who used all 3 modalities lost the most weight, it was in-person visit attendance that accounted for the greatest share of weight loss success. Thus, the internet and mobile app access methods ought not be considered as replacements for the in-person visits but rather as supplements, which does not support their use as an alternative for busy people who don’t have time to participate in person. Additionally, as noted by the authors in their discussion section, the number of components accessed by participants could merely be a marker for level of motivation—thus it was higher motivation levels perhaps driving the weight loss, rather than an additive effect of the 3 modalities. Because motivation to change was not assessed in this study, it is difficult to know what role this factor played in weight loss for the WW participants.
Unfortunately, the trial did not follow participants past the end of the intervention period to determine whether the weight changes were maintained once WW participation was complete. At least 1 prior study evaluating this program, however, showed that despite some weight regain, participants in this commercial program do maintain a larger degree of weight loss than their self-management counterparts at up to 2 years after randomization [6].
The generalizability of these study findings may be somewhat limited based on the demographics of trial participants. Nearly all of them were non-Hispanic white women, which is not too surprising given the nature of the intervention. It does raise an important question, however, about whether similar programs are available for (or of interest to) male and/or non-white patients. While it is possible that the geographic area they sampled from for the study was simply predominated by non-Hispanic white residents, no data were provided about the sampling pool, so one can only assume a somewhat biased response based on the nature of the intervention. Additionally, the patients in this study were, on average, class I obesity patients and lost only a moderate amount of weight. Furthermore, medically complex persons were excluded from participating. Providers caring for patients with more severe degrees of obesity and/or those who have multiple poorly controlled medical conditions should carefully consider whether such patients are appropriate for commercial programs before referring them, and should calibrate their patients’ expectations of the degree and durability of weight loss that will be obtained through such programs.
The participants in this trial received the WW intervention free of charge, which would obviously not be the case for real-world patients enrolling in commercial weight loss programs. Cost, therefore, might be an important barrier to assess prior to referring any patients to such programs. However, the idea of paying for the intervention might paradoxically improve outcomes—the concept of having “skin in the game,” or feeling more compelled to participate in something you have paid for, a popular concept in behavioral economics, could come into play in this context. Paying for WW might “frame” the service as desirable, making people more likely to attend, as opposed to essentially being paid to do it (as in this study), which might have framed it more as a chore, or something undesirable [7].
Finally, given the possible upcoming shift in provider reimbursement for obesity-related counseling heralded by 2012 Centers for Medicare and Medicaid coverage changes [8], providers may become increasingly comfortable managing their patients’ weight loss attempts in the primary care setting, decreasing the need for outsourcing to commercial programs in the near future.
Applications for Clinical Practice
Commercial weight loss programs with combined modalities of in-person, online, and mobile support can provide an alternative to self-directed weight loss, particularly for patients in the demographic groups targeted by such programs. Clinicians who do not feel able to provide such care in the clinical context, or who do not have referral access to clinical weight loss programs might consider referral to commercial programs for some patients. Appropriate selection of patients is important, however, and physicians should consider factors such as financial means, desired amount of weight loss, and medical complexity before recommending such a program. Furthermore, the evidence surrounding long-term maintenance of weight loss after participation in such programs is weak.
—Kristina Lewis, MD, MPH
1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307:491–7.
2. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J Gen Intern Med 2009;24:1073–9.
3. Butryn ML, Webb V, Wadden TA. Behavioral treatment of obesity. Psychiatr Clin North Am 2011;34:841–59.
4. DPP Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.
5. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289:1792–8.
6. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med 2005;142:56–66.
7. Zimmerman FJ. Using behavioral economics to promote physical activity. Prev Med 2009;49:289–91.
8. Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity. 2012.
1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307:491–7.
2. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J Gen Intern Med 2009;24:1073–9.
3. Butryn ML, Webb V, Wadden TA. Behavioral treatment of obesity. Psychiatr Clin North Am 2011;34:841–59.
4. DPP Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.
5. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289:1792–8.
6. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med 2005;142:56–66.
7. Zimmerman FJ. Using behavioral economics to promote physical activity. Prev Med 2009;49:289–91.
8. Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity. 2012.