2. Evaluation of Healthy Choices: A commercial weight loss programme commissioned by the NHS
178 Perspectives in Public Health l July 2011 Vol 131 No 4
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and Rosemary Conley. These
organizations usually provide 12 weeks
of group sessions that cover healthy
eating plans, physical activity and
behaviour change techniques. Similar
group-based programmes have also
been delivered by primary care.
Studies where primary care has
referred patients to a commercial weight
loss programme have found that the
average percentage weight loss at 12
weeks ranged from 3.4% to 6.4%.5,–8
The percentage of patients who lost
≥ 5% baseline body weight at 12 weeks
ranged from 36% to 57%.5,7–9
Similar
group-based weight loss interventions
run in primary care settings have
produced results in the range of 26% to
44%.10,11
This suggests that there is little
difference in weight loss outcomes
between commercial- and primary care-
based interventions. However, many of
these studies did not control for the high
attrition rates, hence the reported results
are probably a best-case scenario.
Dropout rates tend to vary between
different interventions, with rates of 10%
to 80% reported in controlled trials;
however, lower rates would be expected
in routine practice.12
Dropout at
12 weeks within the commercial weight
loss programmes ranged from 32% to
45%.5,7,9
Easily accessible and effective
interventions are particularly important for
individuals disproportionately affected by
obesity, such as those from low
socioeconomic backgrounds. Several
factors have been shown to influence
weight loss in group-based interventions,
such as age, gender, deprivation and
baseline weight. These factors can
influence either attendance or weight
loss, and perhaps both.
Previous studies have reported that
age does not influence weight loss.9,13
However, one study found that people
aged between 35 and 44 years were
more successful at losing weight;10
however, two other studies found that
people aged between 30 and 44 years
had lower odds of success.14,15
There is
also a lack of evidence to support the
efficacy of weight loss programmes in
older people (≥ 60 years).16
Previous
studies suggest that males tend to be
more successful at losing weight
compared to women.8,10,14
However, one
weight loss study of patients who had
type II diabetes mellitus found that
women achieved a greater percentage of
weight reduction than men.17
The relationship between baseline
BMI/weight and weight change remains
unclear. An evaluation of a general
practice referral scheme reports very little
influence of baseline weight on weight
loss.9
A US study supports this, as it
found that baseline weight was not
predictive of weight loss.18
In contrast,
research has shown both that higher
baseline BMI equals greater weight
loss10,19
and people with a BMI ≥ 35
have lower odds of being successful at
weight loss.14,17
Several studies show that weight loss
is positively associated with duration of
attendance.7,9,10,13,19
The number of
sessions attended seems to be a key
predictor of weight loss in a study that
found that participants who were older
were more likely to attend more
sessions.9
Another study found that
baseline weight differed between those
who attended ≥ 10 sessions and those
who did not.18
Healthy Choices is a joint initiative
between the local NHS, Slimming World,
Weight Watchers and a third sector
organization called Healthy Living
Wessex, which provided the referral hub
function. It offers patients 12 free weekly
group-based sessions of practical advice
and guidance to help them lose weight
and lead a healthy lifestyle.
There is currently insufficient evidence
to indicate which individuals are more
likely to attend and lose weight from
being on a group-based weight loss
programme. The aim of the present
study is twofold: the first is to determine
the proportion of participants referred by
a health professional to a commercial
group-based weight loss programme
who lost more than 5% of their baseline
weight at 12 weeks and whether weight
loss success differed between providers
(Slimming World, Weight Watchers). The
second aim is to identify factors that
influence successful weight loss in a
commercial weight loss programme.
These findings can be used to inform
future commissioning of services. This
project is part of a wider service
evaluation.
Method
Participants
Participants were adults over 18 years of
age who were referred by a health
professional to the Healthy Choices
programme in Dorset, UK from 1
October 2008 to 30 September 2009,
and who had a measured BMI ≥ 28. This
inclusion criterion was in line with the
service specification. Patients were
eligible if they were not pregnant, were
ready and committed to make lifestyle
changes, and had not attended a
commercial slimming group within the
previous three months. Questions
regarding the importance, confidence
and priority to make lifestyle changes
were asked by the referral hub to assess
patients’ readiness and commitment to
change.
Data collection
The data recorded at baseline were
height, weight, age, gender, address,
date of referral and referrer, which was
obtained from the referral form. The
referring health professional measured
and recorded the individual’s weight and
height as part of the assessment for
inclusion in the programme. Subsequent
weekly attendance and weight at
12 weeks was collected through the
commercial weight loss providers. These
data were reported to the referral hub on
a monthly basis, where they were stored
and could be extracted in an
‘unidentifiable’ form for up to a year from
enrolment. Ethics approval for the study
was not needed as it was an evaluation
of a routine service.
Statistical analysis
Participants’ measured height and
weight, at baseline and at 12 weeks,
were used to calculate BMI, which was
categorized as healthy, overweight or
obese class I, II and III using the World
Health Organization’s BMI classification.20
Reported postcodes were assigned an
Index of Multiple Deprivation 200721
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score and a quintile within Dorset
(ranked from 1 = disadvantaged to 5 =
advantaged) as an indicator of
socioeconomic status. Weight change at
12 weeks was expressed as a
percentage of baseline weight. A
weight loss of > 5% was classified as
successful. Patients were classified as
‘completers’ if they had attended at least
10 of the 12 free sessions; otherwise
they were classified as a dropout.
Data analysis was undertaken using
SPSS version 16. Participant
characteristics were described as means
(SD) for continuous variables and
percentage for categorical variables.
Group differences were tested using
independent t-tests for continuous
variables and c2
tests for categorical
variables. Logistic regression analysis
was used to estimate predictors of
successful weight loss. Predictors tested
in regression analyses were initial weight,
number of meetings attended,
deprivation, age and gender.
Results
Of the 2,817 participants who were
referred to the programme between
1 October 2008 and 30 September
2009, 2,456 were eligible for inclusion;
361 were excluded because they did not
reside in Dorset. Most (87%) of the
referred participants were given vouchers
to attend a commercial weight loss
programme for 12 weeks. Figure 1
summarizes the participant flow through
the programme.
The characteristics of the participants
are outlined in Table 1. In summary, 87%
of the participants were female and the
mean age group was 45–54 years. The
mean age was 51.1 years (range 18–91
years), while mean BMI was 36.8 (range
23.4–72.9). The BMI range was beyond
the referral inclusion criteria of BMI ≥ 28
due to inappropriate referrals being made
by health professionals. Eleven per cent
(11%) of participants were overweight,
35% were obese class I, 28% were
obese class II and 26% were obese class
III. Over half of the participants were from
the 40% most-deprived areas of Dorset.
Of the 2,456 participants who were given
vouchers to attend the programme, the
dropout rate (attending fewer than
10 sessions) was 36% at 12 weeks.
The main statistically significant
difference between the characteristics of
all participants and completers was
mean (SD) age: completers were
significantly older (53.5, SD 14.7) than
the total sample (51.1, SD 14.98) and
were more likely to be over 55 years of
age. The mean weight loss in all
participants was 4.7 kg (SD 3.8). There
was a significant difference in mean
weight loss between completers (6.1 kg,
SD 3.7) and dropouts (2.2 kg, SD 2.5).
There were no statistical differences in
demographic characteristics between
the two providers, neither were there any
statistical differences between all
participants and completers in respect
to deprivation.
The differences between participants
who had successful weight loss (> 5%)
at 12 weeks and those who did not are
outlined in Table 2. Participants who had
successful weight loss were significantly
more likely to be older, male, with a lower
initial BMI and in obese class I. They
were also significantly more likely to have
attended more meetings (M = 11.2).
There was no statistical difference in
successful weight loss outcomes
between the two providers and between
deprivation quintiles.
Using the logistic regression analysis, it
was found that the number of meetings
attended (OR = 1.56, CI = 1.49–1.64,
p < 0.001) and initial weight (OR = 0.99,
CI = 0.989–0.999, p = 0.02) emerged as
significant predictors. Thus, a higher
number of meetings attended and a
lower initial weight predicted a higher
likelihood of successful weight loss at
12 weeks on this programme.
Discussion
This study of participants referred by a
health professional to a commercial
weight loss programme found that 44%
of all participants achieved a weight loss
of > 5% at 12 weeks. This is comparable
to other group-based weight loss
programmes, however some of these
studies only included patients who
completed the course.
No significant difference was found
between Slimming World (45%) and
Weight Watchers (43%) in the
percentage of people who were
supported in successfully reaching > 5%
weight loss. Two Slimming World studies
report a higher percentage of successful
A summary of the participants flow through the programme
Figure 1
Referred by health
professional
(n = 2817)
87% females (n = 2451)
Excluded
(n = 361)
Completers (attended
10 or more sessions)
(n = 1571)
87% females (n = 1367)
Successful weight
loss at 12 weeks
(n = 955)
85% females (n = 812)
Successful weight
loss at 12 weeks
(n = 118)
86% females (n = 102)
No successful weight
loss at 12 weeks
(n = 611)
89% females (n = 544)
No successful weight
loss at 12 weeks
(n = 754)
89% females (n = 671)
Drop outs (attended
less than 10 sessions)
(n = 874)
89% females (n = 778)
Enrolled
(n = 2456)
87% females (n = 2137)
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to be placed on minimizing dropout in
order to reduce financial wastage to the
NHS and to find a suitable intervention
for the individual. Further research needs
to focus on what factors influence
dropout. One study’s insights into a
commercial weight loss programme
found that older people remained on the
course the longest, and there was no
difference between men and women.
BMI was slightly lower in those dropping
out in the very beginning of the course,
but there was no difference in BMI
between those lapsing at later points or
completers.9
Within the programme, age, gender,
baseline BMI/weight and number of
meetings attended were significant
factors that influenced > 5% weight loss.
People aged ≥ 45 years were more likely
to be successful at > 5% weight loss;
studies from the US that used a number
of weight control strategies support this
finding.14,15
However, other research
findings are inconclusive as to whether
age is a factor9,13
and if it is, which age
groups are predictive of success.10,16
Although this research found that people
who were more likely to be successful
were older, it was shown that this was
because these age groups were more
likely to attend more sessions. Therefore,
future research needs to investigate ways
to keep younger people motivated in
order for them to attend more sessions.
In addition, focus could be placed on
what types and models of weight
management services are most effective
for which age groups.
The number of males referred to this
programme was small compared to
women. Nonetheless, males who
participated in this programme were
found to be more successful at > 5%
weight loss and this seems to be the
conclusion drawn from a diverse range of
weight management studies.8,10,14
However, whether this result is observed
due to physiological gender differences
or the weight management programmes
per se is unknown.
Baseline BMI/weight was found to be
predictive of > 5% weight loss, where
participants who were obese class I were
more likely to have successful weight
loss. Research from other weight
Participants’ baseline characteristics
Variables Total
(N = 2,456)
Completers
(n = 1,571)
p
Age (years)
Mean (SD) 51.1 (14.98) 53.5 (14.66) 0.0001
Age groups (years) < 0.0001
18–24 (%) 4.2 2.7
25–34 (%) 11.8 9.9
35–44 (%) 18.6 16.3
45–54 (%) 21.4 20.2
55–64 (%) 22.6 24.4
65–74 (%) 16.7 20.6
75 and over (%) 4.6 5.9
Male (%) 13 13 0.3
Female (%) 87 87 0.3
Mean BMI (SD) 36.8 (6.3) 36.6 (6.34) 0.66
BMI (kg/m2
) 0.564
Overweight (%) 11 11
Obese class I (%) 35 36
Obese class II (%) 28 27
Obese class III (%) 26 26
Deprivation quintile (IMD score) 0.03
Most deprived quintile (%) 33 32
Quintile 2 (%) 22 24
Quintile 3 (%) 17 18
Quintile 4 (%) 15 15
Most affluent quintile (%) 13 12
Mean weight loss (kg) (SD) 4.68 (3.8) 6.07 (3.7) 0.0001
Table 1
weight loss5,7
but in the main both
providers report similar success (Table 3).
All of these studies were either
conducted as single-provider analysis or
as a comparison with a different provider
than that used in this study. For this
reason, there are limitations in making
direct comparisons with other studies of
Slimming World and Weight Watchers as
no study has compared these two
providers directly with the same service
model and population group.
Nonetheless, this study shows that there
is no difference in the individuals reaching
successful weight loss with either
provider and therefore suggests that
both have a role to play in the future
commissioning of the service. Future
research could look at whether personal
demographics/characteristics or lifestyles
are more successful and suited to a
certain provider to enable appropriate
referral.
The dropout rate for this study was
36%, which is similar to other
commercial weight management
interventions at 12 weeks of 32%,5
37%7
and 45%.9
Although this finding is
comparable to other studies, it is still
perceived to be high with efforts needing
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This study provides some evidence
suggesting the need to refine current
service criteria to ensure that people who
are referred are most likely to receive an
intervention suited to their needs and
with the optimum chance of success to
lose weight.
Conclusions can be drawn from this
research and other studies that weight
loss is positively associated with the
number of sessions people
attend.7–10,13,19
This study found that
people who attended more than
10 sessions were more likely to be
successful at losing > 5% body weight.
Several factors may influence people’s
attendance levels, whether these are life
situations, personal characteristics/
demographics or programme factors that
can be influenced or overcome in order
to support people to reach full
engagement with the programme. For
example, baseline weight was found to
differ between those who attended ≥ 10
sessions and those who did not;18
however, another study reported no
association between duration of
attendance and baseline BMI/weight.9
With these kinds of insights, Healthy
Choices may be able to maximize
appropriate recruitment onto the
programme.
Deprivation was not found to be a
predictive factor of weight loss as no
significant difference was found between
the deprivation quintiles. Research
supports this finding, showing that low-
income women had similar weight loss to
higher-income women.18
This indicates
that this intervention is suitable and
effective for people across all deprivation
quintiles.
Obesity still remains a priority within
the realms of public health as highlighted
in the new Public Health White Paper.22
This research offers insights into what
factors influence successful weight loss,
providing evidence that can inform future
GP commissioning by tailoring the
programme through criteria revisions and
targeting populations for which the
service appears to be successful. Making
these suggested improvements will
maximize cost-effectiveness of the
service by reducing financial wastage to
the NHS and ensuring that appropriate
referral is made whereby the service is
suitable for the individual’s needs.
These changes alone will not make the
suggested improvements happen; the
health practitioners, patients and
providers all have a role to play. Health
practitioners need to ensure that they are
referring patients who fit the criteria and
who are committed to change. Patients
need to be motivated and committed to
fully engage with the programme and
Table 2
Characteristics of participants’ who had successful weight loss (> 5% of
baseline weight) and those who did not
Descriptor
Successful weight loss (> 5%)
pYes (n = 1,073) No (n = 1,365)
Age (years)
Mean (SD) 53.6 (14.4) 49.2 (15.1) 0.0001
Age groups < 0.0001
18–24 (%) 2.4 5.7
25–34 (%) 9.7 13.4
35–44 (%) 15.8 20.8
45–54 (%) 21.0 21.8
55–64 (%) 25.6 20.3
65–74 (%) 19.8 14.2
75 years and over (%) 5.8 3.7
Male (%) 15 11 0.004
Female (%) 85 89 0.004
Mean BMI (SD) 36.4 (6.1) 37.1 (6.5) 0.006
BMI (kg/m2
) 0.004
Overweight (%) 10.5 11
Obese class I (%) 38.8 32.5
Obese class II (%) 27.8 28.6
Obese class III (%) 22.9 28
Deprivation quintile (IMD score)
Most deprived quintile (%) 31 35
Quintile 2 (%) 24 21
Quintile 3 (%) 17 16
Quintile 4 (%) 15 15
Most affluent quintile (%) 14 13 0.25
Initial weight (kg) (SD) 98.99 (19.1) 100.47 (19.46) 0.06
Mean weight loss (kg) (SD) 7.99 (2.9) 2.07 (1.9) 0.0001
No. meetings attended (SD) 11.2 (1.6) 7.9 (3.7) 0.0001
management programmes suggest that
it is unclear whether baseline BMI/weight
is a factor in successful weight loss. A
similar programme reports baseline BMI/
weight not being an influencing factor,9
whereas another study found the higher
the baseline BMI, the higher the weight
loss.10
Other studies support this
research, reporting that people who had
a BMI ≥ 35 had lower odds of achieving
successful weight loss.14,17
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take responsibility to make lifestyle
changes, and providers need to ensure
that efforts are made to motivate and
encourage patients, thereby retaining
them into their programme, reducing
the dropout rate and improving
outcomes.
Limitations
These data were collected as part of a
service evaluation and not for research,
therefore there was no random
allocation, no control for confounding
variables and, due to the requirement of
full ethics approval, no control group.
This means that there is no assurance
that people lost weight solely due to the
Healthy Choices programme.
Nonetheless, there was no selection
response bias as data on all individuals
referred was included in the study.
Data completeness was 97% and
although there were not many variables
used, the data are of good quality as
measurements were objective and not
self-reported.
Large numbers were involved at
12 weeks, however at 24 weeks the data
collected was much reduced and
involved self-report measures, therefore
to ensure robust analysis and meaning,
this study focused only on short-term
weight loss rather than maintenance. The
service accessed a range of individuals
from all deprivation quintiles suggesting a
good representative sample, although
this was using area-based deprivation,
therefore assuming that those who live in
low socioeconomic areas are on a low
income.
Conclusion
As losing and maintaining weight loss is
difficult, it is important to identify factors
that influence success. This research
suggests that age, gender, baseline
BMI/weight and number of meetings
attended are predictors of successful
weight loss. There was no difference
in successful weight loss between
the deprivation quintiles. Neither was
there a difference in the percentage
of people who achieved successful
weight loss between the providers.
The dropout rates were perceived to be
high but were comparable with other
studies.
This research has shown that
working with commercial providers
through the Healthy Choices model
results in successful short-term weight
loss for obese adults, and offers
suggestions that can influence future
commissioning decisions to improve and
maximize the effectiveness of this
service.
Acknowledgements
The authors would like to thank the staff
of the referral hub at Healthy Living
Wessex, Slimming World, Weight
Watchers and NHS Dorset.
Weight loss and dropout rates of adult weight management services
Type of
intervention Study reference
Dropout
at 12
weeks (%)
Average
weight loss at
12 weeks (kg)
Weight loss
at 12 weeks
(%)
People who lost >
5% weight loss at
12 weeks (%)
Slimming World
on referral
Lavin et al. (2006)a
32 5.4 6.4 56.5
Pallister, Avery, Stubbs,
Lavin, Bird (2010)b
n/a n/a 3.4 n/a
Powell et al. (2004) 37 4.8 6 54
Pallister, Avery, Stubbs,
Lavin (2010)b
n/a 4.1 4 36
Weight Watchers
referral scheme
Aston et al. (2007) 45 5.2 5.3 36
Primary care Counterweight Project
Team (2008)
55 3.3 n/a 26
Gray et al. (2009) 24 5 n/a 44
Note: a = data on people who completed at least 10 out of 12 weeks (excludes attendance < 10 weeks and dropout); b = data on
people who finished their 12 weeks no matter how many weeks attended (excludes dropout); c = data reported at 8 weeks.
Table 3
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Paper
1 Craig R, Mindell J. Health Survey for England
2006. Volume 1: Cardiovascular Disease and
Risk Factors in Adults. London: The Information
Centre for Health and Social Care, 2008
2 Foresight. Tackling Obesities: Future Choices –
Project Report. London: Government Office for
Science, 2007
3 Department of Health. Annual Report of the Chief
Medical Officer 2002: Health Check: On the
State of the Public Health. London: Department
of Health, 2003
4 National Institute for Health and Clinical
Excellence (NICE). Obesity: The Prevention,
Identification, Assessment and Management of
Overweight and Obesity in Adults and Children.
London: NICE, 2006
5 Lavin J, Avery A, Whitehead S, Rees E, Parsons
J, Bagnall T et al. Feasibility and benefits of
implementing a slimming on referral service in
primary care using a commercial weight
management partner. Public Health 2006; 120:
872–81
6 Pallister C, Avery A, Stubbs J, Lavin J, Bird M.
Slimming World on referral in partnership with
NHS Bristol: Repeated referral up to 48 weeks.
Obesity Reviews 2010; 11(s1): 236
7 Powell C, Lavin J, Russell J, Barker M. Factors
associated with successful weight loss and
attendance at commercial slimming group.
International Journal of Obesity 2004; 28(s1):
S144
8 Pallister C, Avery A, Stubbs J, Lavin J. Slimming
World on referral: Evaluation of weight
management outcomes when working in
partnership with a commercial organization.
Obesity Reviews 2010; 11(s1): 237
9 Aston L, Chatfield M, Jebb S. Weight Change of
Participants in the Weight Watchers GP Referral
Scheme. Cambridge: MRC Human Nutrition
Research, 2007
10 Counterweight Project Team. Evaluation of the
counterweight programme for obesity
management in primary care: A starting point for
continuous improvement. British Journal of
General Practice 2008; 58: 548–54
11 Gray C, Anderson A, Clarke A, Dalziel A, Hunt K,
Leishman J et al. Addressing male obesity: An
evaluation of a group-based weight management
intervention for Scottish men. Journal of Men’s
Health 2009; 6(1): 70–81
12 Inelmen E, Toffanello E, Enzi G, Gasparini G,
Miotto F, Sergi G et al. Predictors of dropout in
overweight and obese outpatients. International
Journal of Obesity 2005; 29: 122–28
13 Kim J, Park S, Lim Y. Analysis of the factors
affecting the success of weight reduction
programmes. Yonsei Medical Journal 2007;
48(1): 24–9
14 Kruger J, Blanck H, Gillespie C. Dietary and
physical activity behaviours among adults
successful at weight loss maintenance.
International Journal of Behavioral Nutrition and
Physical Activity 2006; 3: 17–27
15 Klem M, Wing R, McGuire M, Seagle H, Hill J. A
descriptive study of individuals successful at
long-term maintenance of substantial weight
loss. American Journal of Clinical Nutrition 1997;
66: 239–46
16 Witham M, Avenell A. Interventions to achieve
long-term weight loss in obese older people: A
systematic review and meta analysis. Age Ageing
2010; 39: 176–84
17 Janghorbani M, Amini M. Patterns and predictors
of long-term weight change in patients with type
2 diabetes mellitus. Annals of Nutrition and
Metabolism 2009; 54: 111–18
18 Samuel-Hodge C, Johnston L, Gizlice Z, Garcia
B, Lindsley S, Bramble K et al. Randomized trial
of a behavioral weight loss intervention for low
income women: The Weight Wise Program.
Obesity 2009; 17: 1891–9
19 Linde J, Jeffery R, Levy R, Pronk N, Boyle R.
Weight loss goals and treatment outcomes
among overweight men and women enrolled in a
weight loss trial. International Journal of Obesity
2005; 29: 1002–5
20 World Health Organization. Obesity: Preventing
and Managing the Global Epidemic. Report of a
WHO Consultation. WHO Technical Report
Series 894. Geneva: World Health Organization,
2000
21 Office for National Statistics. Index of Multiple
Deprivation (IMD) 2007. Available at: <http://
data.gov.uk/dataset/index_of_multiple_
deprivation_imd_2007> Last accessed 06/04/11
22 Department of Health. Healthy Lives, Healthy
People White Paper: Our Strategy for Public
Health in England. London: Department of
Health, 2010
References
at Bobst Library, New York University on June 15, 2015rsh.sagepub.comDownloaded from
