Should We Outsource Obesity Treatment To Weight Watchers?Friday, September 9, 2011
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 🙂