Embed Size (px)
Citation preview
Weight management interventions in primary care
Professor Susan Jebb
Nuffield Department of Primary Care Health Sciences
University of Oxford
Funding
One of the trials (Jebb 2011) was funded by Weight Watchers. This was an
investigator-led protocol, independently analysed and with unrestricted
freedom to publish.
Two ongoing trials (BWeL and WRAP) are funded by the National Research
Prevention Initiative (MRC, DH and a consortium of health charities). The
interventions are provided to the health service at no cost by
WeightWatchers and Slimming World. The commercial partners have no
other role in the studies.
None of the investigators receive any personal renumeration from these
companies for consultancy work, lecture fees or other activities
Access to weight management interventions in primary care
• UK primary care electronic records
• 91,413 overweight and obese patients (BMI > 30 kg/m2)
• Mean age 56 years (30-100 years)
• Interventions more common in women, older people, those with
comorbidity
• People in most deprived areas 25% more likely to be offered an
intervention than those in the top quintile
Booth, Prevost, Guilford. BMJ Open 2015
Proportion of patients offered weight-loss interventions
BMI Category Total Advice % Referral % Drugs %
No treatment %
Men
Overweight (BMI 25-29.9)
30 950 5.8 2.9 0.3 91.4
Obese (BMI (30-34.9) 12 711 8.9 6.0 2.5 84.2
Severe obesity (BMI 35-39.9)
3368 10.8 10.4 9.9 74.2
Morbid obesity (BMI ≥40)
1384 12.1 17.3 23.3 60.0
Women
Overweight (BMI 25-29.9)
24 144 5.5 3.2 1.9 90.3
Obese (BMI (30-34.9) 11 364 8.1 6.5 7.8 80.2
Severe obesity (BMI 35-39.9)
4777 9.7 9.3 14.0 72.4
Morbid obesity (BMI ≥40)
2715 10.5 17.6 26.7 58.1
Booth, Prevost, Gulliford. BMJ Open 2015
0
10
20
30
40
50
60
70
80
90
100
Over weight Obese Severe obesity Morbid obesity
Intervention / 1000 patient years
Rate of weight management intervention by body mass index category (per 1000 pt yrs)
AdviceReferral
Booth, Prevost, Gulliford. BMJ Open 2015
Most patients who are overweight do not receive support to lose weight Why?
• Sensitivities in raising the issue of obesity
• Large number of patients
• Limited time
• Perceived lack of training
• Paucity of treatment options
• Pessimism about long term success
The BWeL Trial: Brief (systematic) interventions for Weight Loss
The intervention (support)
• Offer help
• Book them in
• Create accountability
Theory of change
• To create momentary
motivation
• To capitalise on the
moment
• To create lasting
motivation
Lewis, Jolly, Adab, Daley, Farley, Jebb, Lycett, Clarke, Christian, Jin, Thompson, Aveyard. Trials. 2013 Nov 19;14:393.
Control group (advice) “It would be good for your health if you lost some weight”
Recruitment: 1883 people, 61 practices, 136 GPs Final 1 y measurement due Jan 2016
How appropriate/helpful was the intervention?
Appropriate Helpful
Aveyard et al, unpublished
Acceptance of referral (77%)
Aveyard et al, unpublished
Uptake of support by gender
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Men Women
No referral No booking Did not attend Start but not complete course Complete course
Aveyard et al, unpublished
The BWeL Trial: Brief (systematic) interventions for Weight Loss
• Most patients find very brief interventions related to their excess
body weight very acceptable
• 1 in 500 people find it unacceptable
• A very brief intervention offering help, immediate booking, and
accountability can motivate over 30% (men) and 50% (women)
who are obese, but unselected, to attend a weight management
programme
• 1 y weight change data available mid 2016
Aveyard et al, unpublished
3883 results retrieved
23 studies met our criteria (43 references,
9,623 participants)
186 full text screened
39 interventions: • 18 tailored and interactive • 6 interactive, not tailored • 3 tailored, not interactive • 12 fixed
Systematic review of self-help interventions
18 studies included in quantitative synthesis
(meta-analyses)
Hartmann-Boyce, Jebb, Fletcher & Aveyard. Am J Public Health. 2015 Mar;105(3):e43-57.
Self-help interventions versus minimal controls (BOCF; 6 months)
Study or Subgroup
1.1.1 Tailored and interactive
Byrne 2006
McConnon 2007
Morgan 2011
Morgan 2013
Shapiro 2012Subtotal (95% CI)
Heterogeneity: Tau² = 2.94; Chi² = 24.96, df = 4 (P < 0.0001); I² = 84%
Test for overall effect: Z = 2.11 (P = 0.04)
1.1.2 Interactive non-tailored
Greene 2013
Nakata 2011Subtotal (95% CI)
Heterogeneity: Tau² = 0.00; Chi² = 0.01, df = 1 (P = 0.91); I² = 0%
Test for overall effect: Z = 4.39 (P < 0.0001)
1.1.3 Static
Morgan 2013Subtotal (95% CI)
Heterogeneity: Not applicable
Test for overall effect: Z = 3.25 (P = 0.001)
Total (95% CI)
Heterogeneity: Tau² = 1.52; Chi² = 29.53, df = 7 (P = 0.0001); I² = 76%
Test for overall effect: Z = 3.57 (P = 0.0004)
Test for subgroup differences: Chi² = 1.77, df = 2 (P = 0.41), I² = 0%
Mean
-4.8
-0.6
-5.3
-5.1
-1.3
-2.4
-4.5
-3.5
SD
3.9
3
5.8
5.4
3.8
4.3
3.9
4.7
Total
41
111
34
53
81320
180
62242
5454
616
Mean
-1.9
-0.9
-3.5
-0.5
-0.6
-0.7
-2.9
-0.5
SD
3.4
4.5
5.6
3.4
3.3
4.1
4.1
3.4
Total
33
110
30
26
89288
169
63232
2626
546
Weight
12.0%
15.0%
7.5%
10.7%
14.7%59.9%
15.6%
13.2%28.8%
11.3%11.3%
100.0%
IV, Random, 95% CI
-2.90 [-4.56, -1.24]
0.30 [-0.71, 1.31]
-1.80 [-4.60, 1.00]
-4.60 [-6.55, -2.65]
-0.70 [-1.77, 0.37]-1.81 [-3.50, -0.13]
-1.70 [-2.58, -0.82]
-1.60 [-3.00, -0.20]-1.67 [-2.42, -0.93]
-3.00 [-4.81, -1.19]-3.00 [-4.81, -1.19]
-1.85 [-2.86, -0.83]
Intervention Control Mean Difference Mean Difference
IV, Random, 95% CI
-4 -2 0 2 4Favours intervention Favours control
-1.85 [-2.86 to -0.83]
p = 0.0004
What works in primary care?
Relevant NICE guidance
CG 189: Obesity: identification, assessment and management of overweight and obesity in children, young people and adults
NG7: Maintaining a healthy weight and preventing excess weight gain among adults and children
PH47: Managing overweight and obesity among children and young people: lifestyle weight management services
PH53: Managing overweight and obesity in adults: lifestyle weight management services
PH27: Weight management before, during and after pregnancy
Systematic review of weight loss interventions suitable for routine use in primary care
Included:
– Population
• adults
• BMI of ≥ 25 kg/m2 (or a BMI of ≥ 23 kg/m2 in Asian populations).
– Interventions
• involve multiple contacts with the
• multi-component weight management programmes.
– Studies
• Follow-up for at least a year
Excluded:
– pregnant women,
– people with eating disorders
– Specific treatment for a medical condition
Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev. 2014 Nov;15(11):920-32.
30 studies included
Data synthesis and presentation
• Some studies ignored these participants (completer data only), whereas others included them in the analysis using a variety of methods of imputation.
• The method used can have a big impact on results.
• So that we could compare like with like, for each study, we recalculated the weight change data reported using the baseline observation carried forward approach
There are many ways to treat participants without follow-up data.
Meta-analysis of mean difference in weight loss at 12 months
Baseline observation
carried forward: Intervention versus
minimal contact control (random effects, results as mean difference in
weight change kg)
40 comparisons
Study or Subgroup
Appel 2011 (in person)
Appel 2011 (phone)
Bertz 2012
Dale 2008 (intense)
Dale 2008 (modest)
DPP 2002
Eriksson 2009
Fitzgibbon 2010
Foster-Schubert 2012
Hersey 2012 (arm 2)
Hersey 2012 (arm 3)
Heshka 2003
Jebb 2011
Jolly 2011 (GP)
Jolly 2011 (pharmacist)
Jolly 2011 (RC)
Jolly 2011 (SD)
Jolly 2011 (SW)
Jolly 2011 (WW)
Kuller 2012
Lindstrom 2003
Mensink 2003
Morgan 2011
Munsch 2003 (clinic)
Munsch 2003 (GP)
Nanchahal 2011
Patrick 2011
Penn 2009
Rejeski 2011
Rock 2010 (in person)
Rock 2010 (phone)
Ross 2012
Silva 2010
Stevens 1993
Stevens 2001
Vermunt 2011
Villareal 2011
Vissers 2010 (fitness)
Vissers 2010 (vibration)
Wadden 2011
Total (95% CI)
Heterogeneity: Tau² = 5.12; Chi² = 587.61, df = 39 (P < 0.00001); I² = 93%
Test for overall effect: Z = 7.25 (P < 0.00001)
Mean
-4.8
-5.1
-7.3
-2.5
-2
-6.5
-1.2
-1.96
-8.9
-1.9
-1.8
-4.1
-4.06
-0.8
-0.7
-2.1
-2.5
-1.9
-3.5
-6.4
-4.3
-2.25
-4.1
-0.9
-3.6
-1.3
-0.9
-2
-6.3
-10.1
-8.5
-2
-5.49
-4.5
-1.8
-0.5
-7.7
-6.3
-7.2
-2.8
SD
7.6
7.6
6.3
7.5
6.6
6.6
2.6
6.95
5.5
5.8
5.9
6.5
6.02
5.1
4.5
6.4
5.9
5.1
6.9
7.1
5
3.51
5.4
6.9
7.9
4.3
7.7
4.1
7.7
7.3
8
4.4
5.13
6.3
5.8
4.7
4.5
6.4
6.9
6.4
Total
138
139
16
25
31
1079
75
107
117
579
578
221
377
70
70
100
100
100
100
253
265
55
34
52
53
191
224
51
98
167
164
207
123
308
595
479
28
20
20
131
7540
Mean
-0.9
-0.9
-0.7
-6.1
-6.1
-0.4
-0.6
0.46
-0.7
-1.2
-1.2
-1.1
-1.77
-1.1
-1.1
-1.1
-1.1
-1.1
-1.1
-1.3
-1
-0.2
-2
-0.2
-0.2
-1
-0.2
0.1
-0.8
-2.5
-2.5
-0.8
-1.07
0
0.6
-0.3
0.1
1.1
1.1
-2
SD
4.6
4.6
5.7
6
6
6.4
2.7
5.41
4.6
4.2
4.2
5.4
3.78
5.1
5.1
5.1
5.1
5.1
5.1
5.1
3.7
3.1
4.3
2.7
2.7
4.5
5.7
3.1
7.2
6.2
6.2
5.8
3.69
5.6
6.9
4.9
3.1
3.4
3.4
6.4
Total
69
69
17
11
12
1082
76
106
87
299
299
212
395
16
16
17
17
17
17
255
257
59
31
8
9
190
217
51
93
56
55
208
116
256
596
444
27
11
10
130
5913
Weight
2.6%
2.6%
1.6%
1.4%
1.6%
3.0%
2.9%
2.6%
2.7%
2.9%
2.9%
2.8%
2.9%
2.2%
2.2%
2.2%
2.2%
2.2%
2.2%
2.8%
2.9%
2.8%
2.3%
2.2%
2.2%
2.9%
2.8%
2.7%
2.4%
2.5%
2.5%
2.9%
2.8%
2.9%
2.9%
2.9%
2.5%
1.9%
1.8%
2.7%
100.0%
IV, Random, 95% CI
-3.90 [-5.57, -2.23]
-4.20 [-5.87, -2.53]
-6.60 [-10.71, -2.49]
3.60 [-1.01, 8.21]
4.10 [-0.01, 8.21]
-6.10 [-6.65, -5.55]
-0.60 [-1.45, 0.25]
-2.42 [-4.09, -0.75]
-8.20 [-9.59, -6.81]
-0.70 [-1.37, -0.03]
-0.60 [-1.28, 0.08]
-3.00 [-4.12, -1.88]
-2.29 [-3.00, -1.58]
0.30 [-2.47, 3.07]
0.40 [-2.31, 3.11]
-1.00 [-3.73, 1.73]
-1.40 [-4.09, 1.29]
-0.80 [-3.42, 1.82]
-2.40 [-5.18, 0.38]
-5.10 [-6.18, -4.02]
-3.30 [-4.05, -2.55]
-2.05 [-3.27, -0.83]
-2.10 [-4.46, 0.26]
-0.70 [-3.35, 1.95]
-3.40 [-6.16, -0.64]
-0.30 [-1.18, 0.58]
-0.70 [-1.96, 0.56]
-2.10 [-3.51, -0.69]
-5.50 [-7.61, -3.39]
-7.60 [-9.57, -5.63]
-6.00 [-8.05, -3.95]
-1.20 [-2.19, -0.21]
-4.42 [-5.55, -3.29]
-4.50 [-5.48, -3.52]
-2.40 [-3.12, -1.68]
-0.20 [-0.82, 0.42]
-7.80 [-9.84, -5.76]
-7.40 [-10.85, -3.95]
-8.30 [-11.99, -4.61]
-0.80 [-2.35, 0.75]
-2.84 [-3.61, -2.07]
Intervention Control Mean Difference Mean Difference
IV, Random, 95% CI
-10 -5 0 5 10
Favours intervention Favours control
BWMP vs control: -2.84 kg (95% CI: -3.61, -2.07); p < 0.00001
Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev. 2014. 15(11):920-32
Effectiveness of primary care treatment
Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev. 2014 Nov;15(11):920-32.
.
Primary care vs control: -0.22 kg (95% CI: -0.87, 0.44); p = 0.52
POWeR: Positive Online Weight Reduction
Feasibility trial in primary care with basic or intensive nurse support (n = 179)
Online intervention to support sustainable long-term weight management by helping people form healthy eating habits. Theory-, evidence- and person-based
Designed and shown to be accessible and engaging for most people in primary care (wide age range, tailored for gender, good uptake and adherence by people with limited literacy/computer literacy)
Weekly access to: a) 12 in-depth advice sessions (self-regulation ‘POWeR tools’); b) goal and weight review – tailored feedback based on weight and goal progress entered
Results from feasibility trial
Intervention arm
3 per protocol practices Usual care
(n = 43)
Website only
(n = 45)
Basic nurse
support
(n = 44)
Regular
nurse
support
(n = 47)
Weight change from
baseline at 6 months
(ITT analysis)
-1.56
(C.I. -0.22 to
-2.89)
-1.95
(C.I. -0.76 to
–3.14)
-3.16
(C.I. -1.68
to -5.95)
-4.36
(C.I. -1.40 to
-7.31)
Weight change from
baseline at 12 months
(ITT analysis)
-1.71
(C.I. -0.31 to
-3.10)
-1.76
(C.I. -0.49 to
-3.04)
-4.64
(C.I. -2.29
to -6.99)
-2.12
(C.I. 0.22 to
-4.46)
Yardley et al. Int J Behav Nutr Phys Act. 2014. 21;11:67
Full trial of POWeR+ (just completed)
POWeR+ with face-to-face or remote nurse support (n = 834)
Weekly access for 12 months to 25 sessions plus:
Remote nurse support (3 phone/email contacts + up to 2 optional, weighed every 6 months) OR
Face-to-face nurse support (3 contacts + up to 4 optional, weighed every 6 months)
Preliminary results at 1 y:
81% completed
Weight loss
of ≥ 5kg
Face to
Face
62/221
(28.1%)
Remote 67/218
(30.7%)
Effectiveness of commercial weight management providers
Commercial providers vs control: -2.27 kg (95% CI: -2.81, -1.73); p<0.00001
Hartmann-Boyce, Johns, Jebb, Summerbell, Aveyard. Obes Rev. 2014 Nov;15(11):920-32.
-1.77 kg
-4.06 kg
p < 0.001
78
80
82
84
86
88
Weight(kg)
0 2 4 6 9 12
Time (months)
WW SC
Referral to a commercial provider significantly increases weight loss: BOCF
Jebb et al Lancet. 2011;378(9801):1485-92
• Moderate evidence that commercial programmes are more effective than those delivered by a generalist in a primary care setting.
• Minimum intervention length = 3 months
Managing overweight and obesity in adults: NICE Guidance PH53
The WRAP trial: Weight loss Referrals for Adults in Primary care
To evaluate the clinical and cost effectiveness of 3 weight loss interventions that can be delivered in primary care:
• referral to a commercial provider for 12 weeks (CP12)
• referral to a commercial provider for 52 weeks (CP52)
• a brief intervention (BI)
Primary Research Questions:
• Is 12 month weight loss greater for CP than BI?
• Is 12 month weight loss greater for CP52 than CP12?
Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health. 2014 Jun 18;14:62
1269 Enrolled and Randomised
528 allocated to CP52
455 completed 3 month assessment
360 completed 12 month assessment
528 included in ITT analyses
530 allocated to CP12
405 completed 3 month assessment
339 completed 12 month assessment
528 included in ITT analyses
211 allocated to BI
144 completed 3 month assessment
124 completed 12 month assessment
211 included in ITT analyses
1959 screened for eligibility 12,000 letters sent from GP
● 23 GP Practices
● ~50% > median IMD
Recruitment
● Mean Age 53 years
● Mean BMI 34.5kg/m2
● 68% Female
● 90% White
Baseline Characteristics
BI Mean (SD)
CP12 Mean (SD)
CP52 Mean (SD)
Weight (kg) 96.1 (16.4) 96.6 (17.9) 95.7 (16.4)
Fat mass (kg) 39.2 (9.9) 39.6 (11.8) 39.4 (11.1)
Waist (cm) 110 (11.9) 111 (12.4) 110 (12.7)
Systolic BP (mmHg) 130.6 (15.7) 133.5 (17.2) 133.3 (18.1)
Diastolic BP (mmHg) 79.7 (9.2) 80.7 (9.7) 79.9 (10.0)
Fasting Glucose (mmol/L) 5.8 (1.9) 5.6 (1.6) 5.8 (1.8)
HbA1c (mmol/mol) 41.9 (11.2) 40.9 (9.8) 41.7 (10.4)
Total Cholesterol (mmol/L) 5.5 (1.2) 5.3 (1.1) 5.3(1.1)
LDL Cholesterol (mmol/L) 3.1 (1.2) 3.0 (1.0) 2.9 (1.0)
HDL Cholesterol (mmol/L) 1.6 (0.6) 1.6 (0.6) 1.7 (0.6)
Triglycerides (mmol/L) 1.6 (0.9) 1.6 (0.8) 1.5 (0.7)
Clinical Effectiveness
• Weight, waist circumference, body composition, and blood pressure at 3, 12 and 24 months
• Biochemical measures (blood glucose, HbA1c, triglycerides, total, HDL and LDL cholesterol) at 12 months.
• DNA for subsequent analyses of how genetic variation effects response to the interventions.
Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health. 2014 Jun 18;14:62
Data on Health Care Usage, Quality of Life, and Costs to Participants collected at 0, 3, 12 and 24 months.
Relative cost-effectiveness within the timeline of the trial will be calculated using observed data.
Long term cost-effectiveness will be modelled using a decision analytic model developed for Foresight and used by NICE.
• Data on Health Care Usage, Quality of Life, and Costs to Participants collected at 0, 3, 12 and 24 months.
• Relative cost-effectiveness within the timeline of the trial will be calculated using observed data.
• Long term cost-effectiveness will be modelled using a decision analytic model developed for Foresight and used by NICE.
Cost Effectiveness
Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health. 2014 Jun 18;14:62
Participant Experience
• Semi-structured interviews with participants at 3 months.
• Structured diary entries filled in after first visit to the commercial programme, and visit around 3 months.
• Participant attitudes and experience, including the extent to which the weekly weigh in and the sense of peer support are experienced to be key aspects of the CP
Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health. 2014 Jun 18;14:62
Psychosocial Factors
• Questionnaires completed at 0, 3, 12 and 24 months to measure:
- problem eating behaviours
- flexible and rigid dietary restraint
- hedonic hunger
- autonomous motivation.
• Examine how these psychosocial factors change during and following an intervention and how these are associated with completion of the intervention, weight loss and weight loss maintenance.
Ahern, Aveyard, Halford, Mander, Cresswell, Cohn, Suhrcke, Marsh, Thomson, Jebb. BMC Public Health. 2014 Jun 18;14:62
Weight Change Over Time
BI CP12 CP52 CP vs BI CP52 vs CP12
MAR -3.71 -4.91 -7.23 -2.21*
(-3.53, -0.89)
-2.65* (-3.99, -1.32)
Proportion of participants achieving ≥5% and ≥10% weight loss
Intervention Adherence
Commercial programme (CP) 3 months 12 months
BI CP12 CP52 BI CP12 CP52
Attended ≥2 CP meetings 5% 64% 62% 7% 18% 34%
Attended ≥9 CP meetings (% of those who attended meetings)
2% 77% 73% 8% 78% 78%
Attended an NHS programme 1% 1% 1% 2% 1% 1%
Brief advice • 50% BI participants never/almost never used the booklet • 50% still using it once a week at 3 months • 6% using it every day
Change in cardiovascular risk factors
Mean (SE) Change Adj Difference (95%CI)
BI CP12 CP52 CP52vs BI CP52vsCP12
Glucose (mmol/L)
-0.11 (0.20)
-0.27 (0.10)
-0.54 (0.08)
-0.46* (-0.88,-0.03)
-0.29* (-0.58, -0.003)
HbA1c (mmol/mol)
0.15 (0.69)
-1.49 (0.37)
-2.77 (0.47)
-2.65** (-4.28, -1.01)
-1.31* (-2.47,-0.15)
Triglycerides (mmol/L)
-0.14
(0.07)
-0.23
(0.05)
-0.26
(0.03)
-0.09
(-0.25, 0.07)
-0.03
(-0.14, 0.09)
Cholesterol (mmol/L)
-0.31
(0.10)
-0.32
(0.05)
-0.36
(0.05)
-0.05
(-0.24, 0.14)
-0.04
(-0.17, 0.09)
HDL Cholesterol
0.01
(0.10)
0.02
(0.05)
0.02
(0.05)
0.00
(-0.19, 0.19)
0.00
(-0.13, 0.14)
LDL Cholesterol
-0.27
(0.04)
-0.24
(0.03)
-0.24
(0.03)
0.01
(-0.12, 0.13)
-0.02
(-0.11, 0.07)
Gender bias in weight loss interventions may reflect professional behaviour patterns
It isn’t that I need educating, it’s more that I need motivating [P1]
Participants perceive the commercial provider is better tailored to their needs
Motivation For me...what works is the fact that I
know...I’ve got to go and see
somebody...and I’ve got to explain
why I haven’t lost any weight [P6]
Weight Watchers was a structured plan and the GP was more trial and error yourself [P5]
there’s so many [meetings] around...you don’t have to make an appointment with your GP...flexibility and ease [P9]
Ahern, Boyland, Jebb, Cohn. Ann Fam Med. 2013 May-Jun;11(3):251-7.
Accountability
Structure
Availability
A partnership approach
Allen, Cohn, & Ahern. 2015. British Journal of General Practice
‘It’s not like I didn’t know or don’t know that I’m much too big but it’s not something that people normally bring up. It just seemed like well if my doctor starts sending me letters … now might be a good time.’
‘It would be rather embarrassing to be perfectly honest to go to a weight loss thing and say “Yeah [bangs table for emphasis] thank you for the free Weight Watchers things but I just didn’t bother!” … I don’t want to let down the doctors down.’
Weight regain in BWMP over extended follow-up (BOCF analysis)
Johns, Hartmann-Boyce, Jebb and Aveyard (in preparation)
2225 records identified through database searching
5 additional records identified through other sources
1259 records after duplicates removed
265 records screened 202 records excluded
63 full text articles assessed for eligibility
11 studies included in quantitative synthesis
(meta-analysis) (18 articles)
45 full text articles excluded
• 4 intermittent VLED • 5 VLED vs VLED • 2 surgical comparators • 2 maintenance studies • 21 non-randomised studies • 3 review articles • 6 follow up < 12 months • 2 authors unable to provide data when contacted
Parretti, Jebb, Johns, Lewis, Christian and Aveyard, submitted
Very Low Energy Diets
Very low energy diets enhance weight loss at 1 year
VLED vs BWMP: -4.27 kg (95% CI: -7.41, -1.14); p < 0.00003
Parretti, Jebb, Johns, Lewis, Christian & Aveyard (under review)
The DROPLET Trial
Doctor Referral of Overweight Persons to Low Energy Treatment:
Randomised controlled trial of Very Low Energy Diet programme (Cambridge Weight Plan) compared with Usual Care in Primary Care.
• Obese patients (BMI ≥ 30kg/m2) invited by GP letter (n=270)
• Randomised to Usual Care or Referral to a local Cambridge Weight Plan consultant
Usual Care: Advice from Practice Nurse on weight loss
Cambridge Weight Plan
8 weeks liquid formula products as sole source
4 weeks gradual food reintroduction
12 weeks weight maintenance
• Follow-ups at 12, 24 and 52 weeks
• Primary outcome: Weight change
• Secondary outcomes: including CVD risk factors, HbA1c, QoL
Jebb & Aveyard
The BIG challenge: Scaling Up
To reduce the burden of chronic disease we need interventions for the many and not just the few
• Offer brief advice as part of routine consultations
– Computer prompts?
– Incentives?
• Encourage self-management
• Signpost to effective online resources
• Offer referral to commercial weight loss groups
Key points
• Patients welcome support to lose weight
• Brief advice alone is modestly effective
• Gender bias in interventions may reflect professional behaviour
• No evidence from trials that current interventions delivered by generalist primary care teams are effective
• But - health professionals can motivate people to initiate a programme and sustain adherence
• Referral to weight–loss groups run by commercial providers leads to modest weight loss, is acceptable to patients and cost-effective
• Very low calorie diets lead to greater weight loss but, as yet, rarely used in primary care settings
• Weight regain is common but does not invalidate the benefits of initial losses
• Size matters: need to scale-up to achieve population-level impact
With thanks to:
University of Oxford
• Paul Aveyard
• Nerys Astbury
• Jamie Hartmann-Boyce
• Sarah Morrish
• Carmen Piernas
• Sarah Tearne
University of Birmingham
• Amanda Daley
• Kate Jolly
• Helen Parretti
• Claire Madigan ➡ Sydney
MRC Human Nutrition Research, Cambridge
• Amy Ahern
• Eva Almiron-Roig
• Gina Ambrosini ➡ Perth
• David Johns
• Hannah Lewis
• Celia Walker
Other
• Theresa Marteau, Cambridge
• Eric Robinson, Liverpool
• Peter Rogers, Bristol
October 13, 2015 Presentation title, edit in header and footer (view menu)
Page 50
Thank you for listening
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62
Weig
ht ch
ange
(kg)
Time (Months)
Appel2011
Hersey2012
Lindstrom2003
Mensink2003
Morgan2011
Penn 2009
Ross 2012
Vermunt2011
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62
Weig
ht ch
ange
(kg)
Time (Months)
Dale 2008
DPP
Heshka2006
Jebb 2011
Munsch2003
Rock 2010
Villareal2011
Wadden2011
Weight Change in ‘Control’ Groups No intervention at all; self-help material only or discussions other than weight management
Single weight management session +/- self-help material
Seeing a professional more than once for weight management, +/- self-help material.
Months
REF
Estimated weight change Mean weight change at 12 months = -0.8kg (95%CI -1.1 to -0.4)
Control group ‘intensity’
(as linear trend)
• -0.53kg (95%CI -0.96 to -0.09)
– Adjusted for percentage women and number of weigh-ins; -0.28kg; (95%CI -0.73 to 0.16)
Number of ‘weigh-ins’
(Median=4; range 2-6)
• Every extra weigh-in; -
0.42kg (95%CI -0.81 to -0.03)
– Adjusted for gender; -0.43kg (95%CI -0.79 to -0.07)
– And intensity of intervention; -0.32kg (95%CI -0.71 to 0.07)
When both variables were placed in the same model neither intervention ‘intensity’ or number of weigh-ins were associated with weight change.
Counterweight: Nurse-led support
• 1 hour training for GPs, 8 hour training for practice nurses
• On-going monitoring: 1 – 2 sessions with per month for 6 months
• 65 practices recruited, 56 participated
• 1906 eligible participants (mean age = 49y ; BMI = 37, 77% female)
• 1419 attended baseline assessment, 642 (45%) completed 12 months
• Mean weight loss among completers: -2.96 kg at 12 months Counterweight Project Team. BJGP 2008
Equivalent to approximately -1.33 kg BOCF Adjusted for ‘control’ group -0.53 kg
Weight Change (kg) at 12 months
BI CP12 CP52 CP vs BI CP52 vs CP12
MAR -3.71 -4.91 -7.23 -2.21*
(-3.53, -0.89)
-2.65* (-3.99, -1.32)
Completers -3.28 -5.10 -7.52 -3.12*
(-4.59, -1.65)
-2.53* (-3.66, -1.39)
BOCF -1.93 -3.26 -5.12 -2.26*
(-3.27, -1.25) -1.89*
(-2.71, -1.07)
LOCF -2.30 -3.92 -5.96 -2.64*
(-3.65, -1.62) -2.07*
(-2.89, -1.26)
*P<0.0001
Weight Change Over Time (MAR)
