Reviews
7 April 2015

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review

Publication: Annals of Internal Medicine
Volume 162, Number 7

Abstract

This article has been corrected. The original version (PDF) is appended to this article as a Supplement.

Background:

Commercial and proprietary weight-loss programs are popular obesity treatment options, but their efficacy is unclear.

Purpose:

To compare weight loss, adherence, and harms of commercial or proprietary weight-loss programs versus control/education (no intervention, printed materials only, health education curriculum, or <3 sessions with a provider) or behavioral counseling among overweight and obese adults.

Data Sources:

MEDLINE and the Cochrane Database of Systematic Reviews from inception to November 2014; references identified by program staff.

Study Selection:

Randomized, controlled trials (RCTs) of at least 12 weeks' duration; prospective case series of at least 12 months' duration (harms only).

Data Extraction:

Two reviewers extracted information on study design, population characteristics, interventions, and mean percentage of weight change and assessed risk of bias.

Data Synthesis:

We included 45 studies, 39 of which were RCTs. At 12 months, Weight Watchers participants achieved at least 2.6% greater weight loss than those assigned to control/education. Jenny Craig resulted in at least 4.9% greater weight loss at 12 months than control/education and counseling. Nutrisystem resulted in at least 3.8% greater weight loss at 3 months than control/education and counseling. Very-low-calorie programs (Health Management Resources, Medifast, and OPTIFAST) resulted in at least 4.0% greater short-term weight loss than counseling, but some attenuation of effect occurred beyond 6 months when reported. Atkins resulted in 0.1% to 2.9% greater weight loss at 12 months than counseling. Results for SlimFast were mixed. We found limited evidence to evaluate adherence or harms for all programs and weight outcomes for other commercial programs.

Limitation:

Many trials were short (<12 months), had high attrition, and lacked blinding.

Conclusion:

Clinicians could consider referring overweight or obese patients to Weight Watchers or Jenny Craig. Other popular programs, such as Nutrisystem, show promising weight-loss results; however, additional studies evaluating long-term outcomes are needed.

Primary Funding Source:

None. (PROSPERO: CRD4201-4007155)

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Supplemental Material

Supplement 1. Original Version (PDF)

Supplement 2. Supplementary Material

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James T Langland M.D. 8 April 2015
Fitness and exercise are better than commercial weight loss programs
In their review of commercial weight loss programs Gudzune and colleagues (1) failed to acknowledge that there is no evidence base that dieting induced weight loss reduces either mortality or cardiovascular events in obese individuals. In a large multicenter intensive diet and lifestyle intervention trial, obese and overweight diabetics showed no reduction in cardiovascular events (heart disease, stroke, and cardiovascular-related deaths), despite achieving a 6% loss of body weight with a median follow up of 9.6 years (2). Although the large sustained weight loss associated with bariatric surgery improves mortality in morbidly obese patients (3) similar benefits have not been demonstrated for weight loss from dieting (4). In contrast, improving cardiorespiratory fitness in obese individuals reduces the risk of both all-cause and cardiovascular disease mortality (5). Given the unproven benefits and difficulty of maintaining diet-induced weight loss, clinicians are best advised to focus on improving cardiorespiratory fitness and metabolic risk factors in their obese patients. There is a stronger evidence base justifying the medical management of obesity with improved fitness and exercise than there is for weight loss from dieting and referrals to commercial weight loss programs.

1. Gudzune KA, Doshi RS, Mehta AK, Chaudhry ZW, Jacobs DK, Vakil RM et al. Efficacy of Commercial Weight Loss Programs An Updated Systemic Review. Ann Intern Med. 2015;162:501-512. doi:10.7326/M14-2238
2. The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. N Engl J Med 2013;369:145-54.
doi: 10.1056/NEJMoa1212914
3. Sjostrom L, Narbo K, Sjostrom D, Karason K, Larsson B, Wedel H et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-752. doi: 10.1056/NEJMoa066254
4. Kritchevsky SB, Beavers KM, Miller ME, Shea MK, Houston DK, Kitzman DW, et al. (2015) Intentional Weight Loss and All-Cause Mortality: A Meta-Analysis of Randomized Clinical Trials. PLoS ONE 10(3): e0121993. doi:10.1371/journal.pone.0121993
5. Lee D-c, Sui X, Artero EG, Lee I-M, Church T, McAuley PA et al. Long-Term Effects of Changes in Cardiorespiratory Fitness and Body Mass Index on All-Cause and Cardiovascular Disease Mortality in Men The Aerobics Center Longitudinal Study. Circulation 2011;124:2483-2490. doi: 10.1161/CIRCULATIONAHA.111.038422
Sonja L. Connor, MS, RDN, LD, FAND 23 April 2015
Comment
The recent article “Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review” recommends clinicians refer overweight or obese patients to various commercial weight-loss programs. For more individualized weight-loss – and just as importantly, weight management – services, let me recommend that clinicians refer their patients to a registered dietitian nutritionist (RDN). Through our education and experience, RDNs specialize in translating nutrition science into practical advice that is customized for each individual. Studies confirm positive outcomes and cost-effectiveness of medical nutrition therapy provided by RDNs [1], and surveys show the public recognizes RDNs as a credible source of services. [2] Moreover, increasing numbers of third-party payers are reimbursing for RDNs’ services. The Academy of Nutrition and Dietetics maintains a national, searchable online referral service enabling consumers and health practitioners alike to locate an RDN in their area: http://www.eatright.org/programs/rdnfinder/. As the optimal approach to keeping people healthy involves a team effort, we encourage physicians to include RDNs as part of their team, either in their offices or via referral. Referring patients to RDNs “could be one of the most important ways that health care professionals help patients learn about, implement and sustain behavior changes.” [3]


[1] Bradley D, et al, The Incremental Value of Medical Nutrition Therapy in Weight Management. Managed Care, January 2013, pp 40-45.
[2] 2014 Food and Health Survey, International Food Information Council Foundation. http://www.foodinsight.org/surveys/2014-food-and-health-survey.
[3] Teaching Nutrition and Physical Activity in Medical School: Training Doctors for Prevention-Oriented Care, Bipartisan Policy Center, June 2014. http://bipartisanpolicy.org/library/report/teaching-nutrition-and-physical-activity-medical-school-training-doctors-prevention
Lisa Alley M.S., Susan Thapa MPH, Bryant Phelan MPH, Marie Saylors M.S., Upasana Tiwari M.S. M.D., John Sherrill M.S., Lori Fischbach MPH, PhD* 8 May 2015
A biased review of the efficacy of commercial weight-loss programs
In Gudzune et al’s [1] “systematic review” on “the efficacy” of commercial weight-loss programs, they conclude that “consistent evidence [supports] the long-term efficacy of Weight Watchers and Jenny Craig.” The authors criticize a prior study [2] as not being “representative,” and claim that their study provides “a comprehensive representation of available commercial programs,”[1] yet they excluded the majority of potential studies based on subjective criteria. They excluded more than 2517 studies that “promoted” supplements, 602 non-randomized controlled trials, 134 studies not published in English, 948 studies whose “primary aim was not weight loss” (even when a weight-loss outcome was measured), 113 studies not conducted in a “population of interest” and programs not available across the US. Without any explanation, they also excluded 6 of only 45 studies that did meet their arbitrary inclusion criteria1 (their references 36 and 46-50). For example, they omitted a randomized clinical trial (their reference 36 [1]) that did not find greater weight loss for Weight Watchers versus comparators. Other studies contradicting Gudzune et al’s conclusions include their reference 30, which actually showed greater weight loss in the behavioral counseling group compared to Weight Watchers.

Further, in what the authors claim was an attempt to reduce publication bias, they chose to include unpublished studies, all of which were obtained from the weight-loss programs themselves, and all of which provided favorable outcomes for the companies. This increased publication bias rather than decreasing it. In fact, the vast majority of included studies that Gudzune et al focused on in their “systematic” review were funded by the same companies that Gudzune et al recommend in their conclusions. One exception, which was not funded by these “market leaders,” was the randomized clinical trial that Gudzune et al omitted in their efficacy review (their reference 36).

Of the few studies that were included in this review, the researchers stated that the vast majority conducted intent-to-treat analyses (ITT). However, upon further investigation, analyses labeled as ITTs only included completers (e.g., their reference 22). This also could have inflated the reported efficacy results for the “market leaders” since inevitably all those who completed the program are likely to have a higher percentage of weight loss compared to those who didn’t.

In short, Gudzune et al used biased methods, which produced a non-comprehensive review that is not likely to represent the efficacy of commercial weight-loss programs.

1. Gudzune KA, Doshi RS, Mehta AK, et al. Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med. 2015;162 (7):501-12.
2. Johnston BC, Kanters S, Bandayrel K, Wu P, Naji F, Siemieniuk RA, et al. Comparison of weight loss among named diet programs in overweight and obese adults: a meta-analysis. JAMA. 2014;312:923- 33. [PMID: 25182101] doi:10.1001/jama.2014.10397.
William S. Yancy Jr. MD, Anna Beth Barton MD, Megan A. McVay PhD, Corrine I. Voils PhD 12 May 2015
Presenting Overall Effectiveness in Addition to Comparative Effectiveness
The systematic review by Gudzune et al. underscores the need for enhancing the modest weight loss that lifestyle and/or behavioral interventions typically produce (1). However, the manner in which the review conveys the designs and results of the included trials, while succinct, could be misinterpreted. First, the comparators to the commercial programs are described as “control/education” (i.e., placebo) or “behavioral counseling” (i.e., active control). Behavioral counseling does not completely describe the comparator interventions, many of which included dietary and physical activity counseling over numerous visits and some of which only differed in terms of the macronutrient composition (2-6). Second, results are summarized as mean differences between the commercial programs and their comparators, emphasizing the comparative effectiveness instead of overall effectiveness (i.e., changes from baseline). For example, results for the Atkins studies are reported as “0.1% to 2.9% greater weight loss at 12 months than counseling,” but the weight loss achieved during the study for the Atkins interventions ranged from 3.4% to 12.9%. Thus, reporting additional summary data for an intervention such as mean weight loss from baseline with a confidence interval is also informative. The possible misinterpretation of results presented in this way is demonstrated in the accompanying editorial, which states that these programs resulted in “negligible to modest weight loss (7).” A more accurate statement would be “negligible to modest additional weight loss when compared with programs of established effectiveness.” As many participants have achieved substantial weight loss in these commercial programs, we should be cautious about discouraging their use based on their average comparative effectiveness.

1. Gudzune KA, Doshi RS, Mehta AK, Chaudhry ZW, Jacobs DK, Vakil RM, et al. Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med. 2015;162(7):501-12.
2. Foster GD, Wyatt HR, Hill JO, Makris AP, Rosenbaum DL, Brill C, et al. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial. Ann Intern Med. 2010;153(3):147-57.
3. Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and risk factors among overweight premenopausal women: a randomized trial. JAMA. 2007;297(9):969-77.
4. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359(3):229-41.
5. Yancy WS, Jr., Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004;140(10):769-77.
6. Davis NJ, Tomuta N, Schechter C, Isasi CR, Segal-Isaacson CJ, Stein D, et al. Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes. Diabetes Care. 2009;32(7):1147-52.
7. Wee CC. The role of commercial weight-loss programs. Ann Intern Med. 2015;162(7):522-3.
Kimberly A Gudzune, MD, MPH, Sara N Bleich, PhD, Jeanne M Clark, MD 17 June 2015
Author's Response
Langland states that modest weight loss achieved through lifestyle change has failed to reduce mortality or cardiovascular events, and therefore, referrals to commercial weight-loss programs should be avoided. While we agree that there is no proven long-term benefit for cardiovascular events or mortality, clinical guidelines from AHA/ACC/TOS (1) and USPSTF (2) currently recommend weight loss for its benefits on diabetes, hypertension, and cholesterol. In fact, USPSTF recommends that clinicians “screen all adults for obesity and offer or refer patients with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.” Since most clinicians are not offering multicomponent interventions in their offices, our review is designed to help them discuss commercial weight-loss options with their patients.

Yancy and colleagues note that the term “behavioral counseling” might not completely describe the comparator interventions that included counseling on diet, exercise, and/or behavior modification of varying intensities. We acknowledge the heterogeneity among counseling comparators, which contributed to why we did not present meta-analyses. We provided details about all comparator and intervention arms in Supplemental Table 4. Second, they expressed concern about the presentation of only comparative effectiveness results. Our stated purpose was to compare weight loss of commercial weight-loss programs versus control/education or counseling among overweight/obese adults. Thus, we emphasized comparative results to aid clinicians who are often faced with weighing different treatment options for their patients. In fact, obesity counseling in clinical settings may become even more relevant, as it may be increasingly available to patients given recent benefit expansions within Medicare and through the Patient Protection and Affordable Care Act (3-4).

We briefly address comments made by Alley and colleagues. Our goal was to update a prior systematic review on commercial weight-loss programs (5), and therefore, we developed a protocol a priori based on eligibility criteria from that prior review (Supplemental Table 3). We applied these criteria when screening all abstracts and articles, which resulted in the ultimate inclusion of 45 studies – 39 randomized controlled trials that were included for all outcomes and 6 other trials that were included only in the assessment of harms (Appendix Figure). Their letter includes several inaccurate statements related to the eligibility, inclusion and classification of articles. In particular, we provide clarification regarding their assertion that we included unpublished data. While we considered unpublished data provided by commercial programs, we did not include any in our review as none met our eligibility criteria.

References
1. Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129:S102-38.
2. Moyer VA, U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012. 157:373-8.
3. Centers for Medicare & Medicaid Services. Intensive Behavioral Therapy for Obesity. February 3, 2012. Accessed online at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R142NCD.pdf
4. Congressional Budget Office. Updated estimates of the insurance coverage provisions of the Affordable Care Act. February 2014. Accessed at www.cbo.gov/sites/default/files/cbofiles/attachments /45010-breakout-AppendixB.pdf
5. 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.

Information & Authors

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cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 162Number 77 April 2015
Pages: 501 - 512

History

Published online: 7 April 2015
Published in issue: 7 April 2015

Keywords

Authors

Affiliations

Kimberly A. Gudzune, MD, MPH
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Ruchi S. Doshi, BA
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Ambereen K. Mehta, MD, MPH
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Zoobia W. Chaudhry, MD
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
David K. Jacobs, BA
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Rachit M. Vakil, BS
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Clare J. Lee, MD
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Sara N. Bleich, PhD
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Jeanne M. Clark, MD, MPH
From Johns Hopkins University School of Medicine; Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology, and Clinical Research; Johns Hopkins Bayview Medical Center; and University of Maryland School of Medicine, Baltimore, Maryland, and Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey.
Financial Support: Dr. Gudzune was supported by a career development award from the National Heart, Lung, and Blood Institute (K23HL116601). Ms. Doshi was supported by the Johns Hopkins medical student summer research program. Mr. Jacobs was supported by the medical student research program in diabetes at JHU-UMD Diabetes Research Center (National Institute of Diabetes and Digestive and Kidney Diseases grant P30DK079637). Dr. Bleich was supported by a career development award from the National Heart, Lung, and Blood Institute (1K01HL096409).
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2238.
Corresponding Author: Kimberly Gudzune, MD, MPH, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, 2024 East Monument Street, Room 2-621, Baltimore, MD 21287; e-mail, [email protected].
Current Author Addresses:Dr. Gudzune: Division of General Internal Medicine, The Johns Hopkins University School of Medicine, 2024 East Monument Street, Room 2-621, Baltimore, MD 21287.
Ms. Doshi: The Johns Hopkins Hospital, 600 North Wolfe Street, Harvey/Nelson Room 110, Baltimore, MD 21287.
Dr. Mehta: Department of Medicine, The Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.
Dr. Chaudhry: The Johns Hopkins University, University Health Services, 933 North Wolfe Street, Baltimore, MD 21205.
Mr. Jacobs: The University of Maryland School of Medicine, Office of Student Affairs, 655 West Baltimore Street, Baltimore, MD 21201.
Mr. Vakil: Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854.
Dr. Lee: Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287.
Dr. Bleich: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 454, Baltimore, MD 21205.
Dr. Clark: Division of General Internal Medicine, The Johns Hopkins University School of Medicine, 2024 East Monument Street, Room 2-617, Baltimore, MD 21287.
Author Contributions:Conception and design: K.A. Gudzune, R.S. Doshi, D.K. Jacobs, S.N. Bleich, J.M. Clark.
Analysis and interpretation of the data: K.A. Gudzune, R.S. Doshi, A.K. Mehta, D.K. Jacobs, S.N. Bleich, J.M. Clark.
Drafting of the article: K.A. Gudzune, R.S. Doshi, A.K. Mehta, D.K. Jacobs, S.N. Bleich.
Critical revision of the article for important intellectual content: K.A. Gudzune, R.S. Doshi, A.K. Mehta, Z.W. Chaudhry, D.K. Jacobs, J.M. Clark.
Final approval of the article: K.A. Gudzune, R.S. Doshi, D.K. Jacobs, R.M. Vakil, C.J. Lee, S.N. Bleich, J.M. Clark.
Statistical expertise: K.A. Gudzune.
Administrative, technical, or logistic support: K.A. Gudzune.
Collection and assembly of data: K.A. Gudzune, R.S. Doshi, A.K. Mehta, Z.W. Chaudhry, D.K. Jacobs, R.M. Vakil, C.J. Lee.
* Dr. Gudzune and Ms. Doshi contributed equally to this work.

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Kimberly A. Gudzune, Ruchi S. Doshi, Ambereen K. Mehta, et al. Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review. Ann Intern Med.2015;162:501-512. [Epub 7 April 2015]. doi:10.7326/M14-2238

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