Friday, September 9, 2011

Should We Outsource Obesity Treatment To Weight Watchers?

Yesterday, I posted on Alberta’s plan to tackle obesity by beefing up prevention and treatment efforts across the province.

Today, I discuss a paper by Susan Jebb and colleagues, just published online in The Lancet, comparing weight loss in people randomised to either ‘standard’ care with their physicians or to Weight Watchers.

An accompanying editorial, suggest that doctors (or health systems) should perhaps give up on obesity treatments, as commercial programs (e.g Weight Watchers, Jenny Craig, etc.) do a much better job of this and may cost less.

In this parallel group, non-blinded, randomised controlled trial, 772 overweight and obese adults were recruited by primary care practices in Australia, Germany, and the UK. Participants were randomly assigned with a computer-generated simple randomisation sequence to receive either 12 months of standard care as defined by national treatment guidelines (n=377), or 12 months of free membership to Weight Watchers (n=395).

While only 61% of Weight Watchers participants completed the 12-month assessment, even fewer (54%) of standard care participants showed up for their 12-month assessment.

Perhaps, not surprisingly, participants in the commercial programme group lost twice as much weight as did those in the standard care group (−5·06 kg vs. −2·25 kg) at 12 months.

Based on these findings, the authors enthusiastically conclude that:

“Referral by a primary health-care professional to a commercial weight loss programme that provides regular weighing, advice about diet and physical activity, motivation, and group support can offer a clinically useful early intervention for weight management in overweight and obese people that can be delivered at large scale.”

Sure, but the question here is, for whom (or, in other words, for which patients) and, perhaps more importantly, with what benefit?

So who took part in this study: it would probably be fair to describe the participants as essentially healthy, slightly overweight, pre-menopausal women – in fact, the usual people, who show up at most commercial weight loss programs.

To be exact, the participants were 85% female, in their mid-forties, mildly obese at best (BMI ~31), and had perfectly normal blood pressures (124/78 mmHg), the occasional diabetes (6%) and a metabolic profile that would hardly raise an eyebrow from most health professionals.

While weight loss appeared to move some of these variables in a ‘positive’ direction, one would be hard pressed to find the odd parameter that barely reached ‘statistical’ significance (let alone ‘clinical’ significance) – most clinicians would probably consider these changes little more than ’rounding errors’.

So what the study really shows is that if you randomise a group of otherwise healthy low-risk marginally overweight/obese women to a (albeit, admittedly great) commercial weight loss program, they do better at losing weight than when told to do so by their doctors (or other health professional) – and I’ll certainly believe that.

While I can see why the sponsor (Weight Watchers) and the authors (for publishing in The Lancet) may be celebrating, I see nothing in this study that would make me more enthusiastic about ‘outsourcing’ obesity treatments to a commercial Weight-Loss program).

And here are my reasons:

1) The people, who typically seek out commercial weight loss programs (like the participants in this study) are not who the obesity epidemic is really about. As we recently demonstrated in our large Edmonton Obesity Staging System (EOSS) papers, ‘healthy’ overweight and obese people (male or female) have very little if any health risk from their extra weight and should probably be left alone (certainly not be encouraged to lose weight). No one has yet demonstrated any long-term benefit of weight loss in this ‘healthy’ (Stage 0) obese population and there is far more potential to do harm than good (especially, when the weight comes back, as it most likely will – often with a vengeance).

2) While there is no doubt that Weight Watchers probably offers one of the most evidence-based and effective weight management programs (and is to be highly commended for investing in this study), it is hardly a model for everyone. Very few people have time for weekly meetings and weigh ins and high drop-out rates are the rule rather than the exception – for those, who can do it and enjoy such meetings, great – for most people, this is simply not a realistic option.

3) For all of its competence, expertise, knowledge and investment into offering a high-quality program, the delivery is by trained (and certainly very enthusiastic) lay people – this is why this model works great for ‘healthy’ obese folks. The minute we begin looking at obese people with real health problems, who need lab work, adjustments to their medications, close monitoring of their exercise and nutritional status, the notion that a trained ‘lay person’ alone can be of help is naive at best. Thus, you would in the end be paying double – money to Weight Watchers for weight loss, and still have to see your physician or nurse for managing your comorbidity (albeit perhaps not quite as often as weekly). In fact both Weight Watchers and the authors are careful in pointing out that the study only shows that Weight Watchers in conjunction with a primary care practitioner may be the way to go.

4) Although, much effort has gone into developing the Weight Watchers program and they certainly touch on many of the important aspects of healthy eating, activity, sleep, emotional eating, etc., in the end there is no formal etiological assessment or consideration of the actual causes of excess weight in a given patient. Obviously, I would neither expect a ‘lay program’ to appropriately diagnose depression, anxiety disorders, ADHD, binge eating, chronic pain syndromes, PCOS, obesogenic medications, or any of the other 200 causes of obesity that I can think of. In the end commercial weight loss programs sell weight loss and not obesity treatment.

5) Rather than interpreting this study as showing how great the Weight Watchers program is (and it is without question by far one of the best commercial programs out there), this study actually shows how miserable ‘standard’ care for obesity is – or not? Perhaps the health professionals were indeed smart enough to recognise that very few (if any) of the participants in this study had anything to gain in terms of improving their health from losing weight, and so put little effort into actually doing anything about it. Certainly, in my practice, I would not be wasting my nurses’, dietitians’, psychologists’, or anyone else’s time by referring the majority of these ‘participants’ to any weight loss interventions in our clinic.

The messages for me from this study are loud and clear:

1) ‘Standard’ care is clearly below standard (assuming that we’d see the same result if the participants actually did have a medical reason to lose weight).

2) We need to tell more people that losing weight when you are otherwise healthy may not actually be of any real benefit (of course, we could argue that if Weight Watchers just helped people eat healthier and be more active without any weight loss, they’d probably have the same impact on participants’ health (or not) – but then, who’d pay for that?)

The idea that, based on this study, anyone would even playfully (let alone seriously) suggest that obesity treatment should perhaps be best left to commercial weight loss programs, is not only ludicrous but reflects a rather simplistic view of what I (and many others) would consider a pretty complex and often complicated chronic disorder.

This is not to say that there is no role for Weight Watchers in helping people better manage their weight (and health?).

Weight Watchers, through its network of group meetings and online resources, certainly has the ability to reach far more people than doctors or nurses sitting in their offices.

I would also not be surprised if Weight Watchers has perhaps done more to educate people on healthy eating than anyone else.

Certainly, they have invested more in backing their program with hard evidence than any other commercial weight loss program.

But if Weight Watchers really wants to put their money where their mouth is, and help people not just lose weight but actually get healthier, I’d now like to see a similar study in EOSS Stage 2/3 patients.

I guess, they know where to reach me :)

AMS
Edmonton, Alberta

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19 Responses to “Should We Outsource Obesity Treatment To Weight Watchers?”

  1. AcceptanceWoman says:

    The biggest issue is that while a commercial weight loss program may be more effective in promoting short-term weight loss (12 months is not long at all), no one quibbles that losing weight is possible. What’s far less possible is retaining weight loss, and as you say, “the weight may come back with a vengeance” — and what will the patient have lost then, other than money? Self-esteem, confidence, trust in the entity that either referred or paid for the treatment, valuable muscle mass? Not to mention that they may have developed some eating/dieting habits that are not only difficult to maintain long-term, but they may have relied on packaged/processed foods that are more expensive and less healthy than foods they previously had as part of their diet.
    Weight Watchers helps many people lose weight. But it has not ever shown that people maintain their weight losses over the long-term (I would be happy with a 4-year study) any better than they do with any other program. If one wants to stay on Weight Watchers forever (as many of the lay leaders do), even then, they are likely to find at least some weight creeping back on, due not to individual failure, or the failure of Weight Watchers, but because of the metabolic mechanisms at play.
    Rather than spending scarce health care resources on Weight Watchers, I would think that providing opportunities for larger folks to be physically active and have better access to healthier foods, and improving their medical care, would be a far better investment.

  2. Anonymous says:

    Dr Susan Jebb was paid by weight watchers a few years ago, as a ‘advisor’. I still wonder where she spends the tax payers money in some of the studies she does, like portion control, we know it works but why pump more money into something that is very well known and understood. Well the food industry does have a long arm to sway decisions. the main attributes is to understand why we over eat and how do we stop ourselves, to understand this would be the greatest challenge and the greatest benefit.

  3. Louise Aspden says:

    I am one of those “lay leaders” with WW and have been for over three years now. I agree with Accpetance Woman when she says we need to change the obesegenic environment that we live in which makes it increasingly difficult to maintain a healthy lifestyle.

    I agree with Arya that no commercial program can provide everything a morbidly obese person needs to lose weight and get healthy. It is such a complex ailment. We consistently ensure our members know that Dr.’s orders/meds. come first and foremost, we are there to help them develop a healthy lifestyle in addition to the medical care they receive.

    However, it literally blows my mind that you would say that mildly obese people are not a health risk. I see it every day in reduced blood pressure, blood sugar levels, less knee and joint pain…the list goes on. This is for people losing anywhere from 20 – 120 lbs. It makes a difference. It is also about “nipping it in the bud” where do you think your morbidly obese patients started? Wouldn’t it make sense to get help before they are so far behind the proverbial “8 ball” when it then becomes nearly impossible to overcome?

    One more thing about the leaders at WW. We are all “Lifetime Members” which is to say we have LOST weight and continue to MAINTAIN our weight. We are armed with one of (if not THE) best programs out there. We struggle with the same issues as most of our members – and that gives them something they may not see in a clinic…EMPATHY & SUPPORT from us and the other members. That is invaluable.

  4. Arya M. Sharma, MD says:

    @Louise Aspden: I am with you that WW is one of the best programs and that the support is most useful.

    I also have no doubt that people with weight-related health problems will benefit from losing weight with WW (if they keep it off) – the problem with this study was only that not many of these participants had such problems.

    As for nipping obesity in the bud – this can be achieved simply by stopping the gain – no weight loss required!

  5. DebraSY says:

    Dr. Sharma, you are generous with your adjectives to describe WW. I am not familiar with the current study, and will try to find time to read it. This is an earlier study on Weight-loss maintenance following loss on the WW program that I AM familiar with, and it will color how I look at the study you review here: http://www.nature.com/ijo/journal/v25/n3/full/0801521a.html

    Notes and thoughts: 1. One of the scientists is an employee of Weight Watchers

    2. The narrative is very positive, downright gushy, about the success of WW long term. (Points one and two are likely related.) If you were to read the narrative without really delving into the tables and thinking about their content, you would think WW is darned spectacular. In the narrative, they average five years of results, so that the dismal success rate of those participants at five years is “watered down” by the one-year participants. They bold and emphasize positive features, that, upon contemplation, are not all that positive. For example, at five years, 70.3% of participants were below initial weight (bold face). Sounds exciting till you look at the tables, where you find that most are BARELY below initial weight, and it occurs to you (doing simple math) that nearly 30 percent had GAINED weight.

    3. The most telling part of the study I’m citing is table 4. At five years, only 3.9 percent of participants were “below goal weight.” Admitted, even THAT would be impressive compared with most weight-loss programs; however, elsewhere in the narrative, “goal weight” was defined NOT as the participants’ stated goals, but as a more modest goal assigned by WW to each participant for the purpose of this study. Giving WW a little credit, at five years 18.8 percent of participants were maintaining a 10% loss. That’s a specific, quantifiable measure that resists tampering, and it is more impressive than most programs. (Though it’s still horribly disappointing to lay people who have a Biggest Loser expectation that at five years they’ll still be living the zippy, healthy lifestyle that will maintain ALL their weight-loss, not a stinking 10 percent.)

    All of that said, to call WW a “great” program is a bit generous on your part. At least they do conduct research on their long-term success, and I give them credit for that. And they included tables. They could have just issued a press release, sans study, sans tables, and the mainstream media would have slurped it up anyway, because we’re all wanting the big fix to this complex problem. WW, at least, is contributing to the marketplace of ideas and TRYING to be honest and helpful, despite its biases. The other programs disguise their miserable long-term results entirely and rely on asterisks: “*results not typical.”

    Keep up your good work. I know you need to be more generous with your language than I do. You may see these people at conferences and such, and I don’t have that concern.

  6. Jim says:

    Arya,

    You know my history better than most. While I hear and I agree with much of what you are saying, I agree completely with Louise Aspden. I don’t know at which “EOSS Stage” of obesity I was/am, but I have lost 163 lbs. and kept it off, without bariatric surgery. My “weight loss” program of choice, as you know, is Weight Watchers. Why? Because the Weight Watchers program is credible and it’s evidence-based. It’s the closest thing that I’ve found to incorporating many of the things that you have to do in order to help better manage your weight. And, believe me, I’ve researched and tried them all – Dr. Atkins, Cabbage Soup Diet, Jenny Craig, Nutri System, Dr. Bernstein, Herbal Magic, LA Weight Loss Clinic – need I continue?

    I can certainly understand the reluctance of the Edmonton Weight Wise Clinic, for legal and other reasons, to endorse any Commercial Weight Loss program.

    However, in addition to the multi-discipilinary guidance, advice and help we receive from dieticians and other professionals at your clinic, for example, many of us also need further help with the “weight loss” component of our obesity management.

    I’m not saying that the Weight Watchers program is the be all and the end all, because it’s not. But, as I said, it’s the closest that I’ve ever found in commercial weight loss programs to having a “patient” do a lot of the things you should be doing to help you better manage your weight and, it’s based on credible evidence.

    The new Weight Watchers Points Plus program is also based on over four years of solid, scientific research, where, among other things, the complete package of nutritional contents of all the foods were analyzed – not just simply calories, fat and fiber – taken into consideration and Points Plus values assigned to these foods accordingly. Hence, a food containing a lot of carbohydrates, for example, has a higher Points Plus value than a lean protein because it takes the body more energy to burn lean protein vs. something with a lot of carbs. in it. I know this is tremendously simplifying the reality, but you get my message.

    Bottom line – some of us suffering with obesity require additional help with the weight loss component of our obesity management programs. Weight Watchers is simply the best commercial program out there to give us that help. Period.

  7. Wendy H. says:

    A great article, as always. I have a number of friends and relatives who are having great success with the Weight Watchers program but they all fall into the profile you describe–basically healthy, menopausal, coping more with the results of age more than anything else. Weight Watchers is great for those people, because it’s not a stringent diet. It is a program that allows for a lot of flexibility and freedom which allows one to incorporate it fairly easily into one’s life. But–again, as you say–those of us with health issues, who are morbidly obese, need different approaches.

  8. NewMe says:

    As I came to Jim’s response, a question came to mind. What is the success rate of WW–or for that matter any other commercial weight loss program–when broken down by gender? I would not at all be surprised if males were able to lose weight, and more importantly maintain the loss, much more easily than females.

    I don’t think that gender differences are explored enough when it comes to this already deeply complex situation.

    Dr. Sharma, have you written anything regarding gender and weight loss?

  9. Beth says:

    I think that the bottom line here is that just because Weight Watchers produces slightly better results than “standard care,” it does not necessarily follow that Weight Watchers is either an effective program or a wise use of anyone’s money. What I find troubling is that the entire medical and health policy communities keep focusing on “treatments” that encourage individual’s to change their personal behavior in unnatural and unsustainable ways. (Any diet, where an obese individual is asked to “choose” to consume the amount that would naturally satisfy a normal weight counterpart is unnatural and unsustainable.)

    One of my personal favorite posts on this site calls into question the very notion that “personal choice” has anything meaningful to do with weight loss: “Is It Time To Abandon The Notion Of Personal Choice In Dietary Counseling?” (from Aug. 10th, 2011). If only the larger medical community *would* abandon such ideas! Perhaps if researchers began to truly understand what is happening in an obese individual (metabolically, hormonally, neurologically) who “knows” what to do, but finds themselves nearly helpless to do it, we might find a truly effective treatment.

    As an aside, the myth of “personal choice” also keeps us from recognizing how imperative it is to demand change in our obesogenic environment on a national and global scale, and it contributes to the widespread prejudice many have for obese individuals. The attitude seems to be that if we just heap on enough shame, scorn, and dire warnings, obese individuals will finally “get it,” seek help, admit their dietary sins, count points, choose the salad, and push away from the table. If only it were that easy.

  10. anon says:

    I find this whole premise absolutely horrifying! – but oh so helpful in that I’ve lose my appetite.

    What is the difference between private health care and commercial health care? Why not promote getting a whole chain of “Watchers” going? Get the government out of health care altogether! – for hemophiliacs we could have “Blood Watchers”. For Alopecia we could have “Hair Watchers”. For Diabetes we could have the “Water-Intake/Bathroom-Output Watchers”. Let’s go through the list of diseases and get “Watchers” for all of them! Hmm… I wonder which ones I’ll be able to claim for through my private “watcher care” insurance?

    Success stories always appeal to the authority of their success! Sure there are Jareds out there for whom the “Subway” connection has been a miracle and so too with Weight Watchers. I agree that the educational side of Weight Watchers could be very helpful but it’s just kindergarten health class. Speaking of which, kindergarten health class is gaining momentum for promotion. Let’s encourage it more! – introduce it in grade 1 – …government implementation needed here…Get past the government barrier and then implement “buddy-body power” through more weight wise clinicians and psychologists (pay them not commercialists). The team of professionals at the weight wise clinic is, to my mind, much more adept than those offering expressions of empathy and the “if I can do it, you can too” attitude at Weight Watchers. And from an educational side of things, as I have begged before, provide each child or at least each classroom a plastic food kit with lots of food types showing portion contro over a week. Kids learn math in kindergarten. They use a graphing calculator by grade 10 and already understand mitosis and meiosis! They learn about the waxing and waning of the moon in grade 2. They can certainly do the math! … they could learn so much more about health and metabolism if only they could be empowered. Weight Watchers, to me, is yet another adult based reactive program that, based on their pre-summer and post-Christmas blitz, is profit based.

    Dr. Sharma why don’t you just ask all of your readers and bariatric patients if they have tried weight watchers and to what extent it helped them. Then report back to your blog. Tick me off for “been there done that – no where near what I needed and failed/bailed out – at least three times.” – not to mention lost big bucks in the process that I shoulda spent on activity or a restful vacation.

  11. Arya M. Sharma, MD says:

    @NewMe: “Dr. Sharma, have you written anything regarding gender and weight loss?”

    Of course I have :) :

    http://www.drsharma.ca/obesity-is-unfair-to-women.html

  12. A Cardiologist Gives a History of How We Got So Fat And Sick. « Alternative Health Answers says:

    [...] Should We Outsource Obesity Treatment To Weight Watchers? (drsharma.ca) [...]

  13. Linda says:

    I have tried WW so many times I should own shares in the company! Yes, it promotes a very healthy program and over the years I have implemented many of the things I learned there into my lifestyle. My problem is that I can eat healthy all week long (which is what I normally do) and then have an emotional eating binge for one or two days and all efforts at weight loss are gone. Very, very frustrating for me over the years. This is the reason for my constant in and out of WW and other commercial weight loss programs. Too expensive and embarrassing week after week to look like/feel like a failure. I have spoken to many people with mild to severe obesity and for them this is what the cycle is also. If I could just learn how to get hold of my emotions and stop using food as a comfort measure I would be healthy and slim! I don’t find the commercial programs really addressing this problem. I work out hard at the gym 3 days/week and various other exercise on 3 more days. I use a personal trainer who upgrades my program every 8 weeks or so. I am maintaining a 45 lb weight loss (over 2 yrs now) but have plateaued for the past 6 months. Still have at least 70 more to go. Thanks again Dr. Sharma for all you are doing. Keep up the good work.

  14. fredt says:

    What separates the commercial programs is the weekly scheduled education sessions, at a reasonable time and location, and the willingness of the participants to do what is necessary to recover. Education about food and a eating program that actually works is the key.

  15. Mitzi says:

    I think the relevant question for the commercial weight loss programs as well as others is, “how do we get people to stick to a new way of life, long-term?” I have a connective tissue problem that gives me major digestive issues if I do not eat a plant-based diet. My muscles de-condition to the point of joint dislocation if I stop going to the gym. It is a painful disorder, but it forces me to live a healthy lifestyle. How do you get normal people, not faced with this kind of motivation, to choose health when junk food and the couch are calling? Obviously medical intervention is often necessary, though for a neighbor of mine the thought of wearing a “tent” to her son’s wedding was more motivating than a doctor’s warning that she would be dead in 10 years. Social support is critical. Education, access to healthy food and exercise, and accountability count. But more is needed. The real research topic should be, “What more?”.

  16. Trish Cherry says:

    I agree with the comments that weight watchers do get into the habit of watching what they eat, and learn more bout healthy eating habits. What they and countless thousands of Nutritionists, Dietitians etc do not and seemingly will not take in to account is the nature of addiction.

    You can be addicted to sugar, and consequently certain carbohydrates, (because the body converts carbs to sugar) The more of these foods you eat the more you want. Processed foods have no or very little nutrition, and most of them contain sugars of one sort or another.

    Weight Watchers have a line of foods that they manufacture (dont forget they are part of the Heinz group who manufacture their own foods) that contain loads of additives, e numbers, and of course sugar.

    The original idea was to help people who needed to lose weight, but now they are just simply part of the great food con.

  17. RedPanda says:

    I’ve lost 90 pounds, going from being morbidly obese (a BMI of 40 with sleep apnea) to a BMI of around 23, and maintained at that level for nearly eight years – with no thanks to Weight Watchers.

    As others have mentioned, Weight Watchers may help some people due to the supportive nature of the meetings, but not not everyone has the time to attend meetings. Also, when I attended WW meetings back in the day, I found them to be infantilising at best and depressing at worst.

    My criticisms of WW are (1) not enough attention paid to the role of exercise in losing weight – and more importantly – keeping it off; (2) related to the first point, just not enough calories to sustain an active lifestyle, let alone an athletic one; (3) as others have mentioned, a reliance on processed and sugar-laden foods; and as Anon pointed out, a level of nutritional advice that’s akin to “kindergarten health class”.

    And as Anon also pointed out, farming out obesity treatment to a commercial company like Weight Watchers is unethical.

  18. Interesting reads: September 3rd – 10th, 2011 « Mr Epidemiology says:

    [...] more scientific news, Dr Arya Sharma reviews a paper recently published in the Lancet about the effectiveness of Weight Watchers, and if we should outsource weight-loss efforts to them. [...]

  19. Nancy Anderson Dolan says:

    In our research on people who have maintained a weightloss over 100 lbs for over 1 year most had started out in Weight Watchers or similar commercial weight loss programs when they were not morbidly obese and they were these “successful” losing weight ones like the study – also our clients that identify as food addicts tell us how they kept trying WW but becasue it included the the foods that triggered them they never maintained their success. What we know is that chronic weight issues are complex problems that require comprehensive intervention. Now I still have assisted clients in using that program as one part of their treatment plan becasue of it’s accessiblity and affordability, we just point out the things that may be problematic for them and work within their unique needs teaching them to use this and other diverse services to get the total intervention they need – got to work with the resources availble right – thanks for putting the discussion on the table

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