A randomised controlled trial to test the clinical and cost-effectiveness of primary care referral to a commercial weight loss provider.
Lead Research Organisation:
MRC Centre Cambridge
Department Name: MRC Human Nutrition Research
Abstract
Overweight and obesity is a serious public health issue due to its high prevalence and association with illnesses, such as Type II diabetes, heart disease and cancer. Early treatment and prevention are important if we are to reduce the health problems associated with excess weight, but there are few treatments available through the National Health Service (NHS) and those that are available can be very costly when we consider the number of people requiring treatment. It is in the interests of the NHS to offer (cost-effective) weight loss treatment options, as they spend £4.2 billion each year on treating illness related to overweight and obesity. The cost to the wider community is estimated at £16 billion. This study seeks to examine one of the treatment options currently available on the NHS - referral to a commercial weight loss treatment provider - and to establish whether this treatment option is cost-effective in helping people to lose weight and keep it off.
Previous research has shown that referring a patient for 12 sessions with a commercial weight loss provider can produce an amount of weight loss which has significant health benefits. These referral packages are offered to the NHS at a discounted price, however no studies have formally evaluated the cost-effectiveness of this approach. This study will examine whether the money spent on treatment is worthwhile when we consider the effect of improved health for patients and also potential cost savings on treatments for weight-related illness. But weight regain is common after weight loss treatment stops and it may be that 12 weeks is not long enough to develop long term changes in behaviour. It is not hard to imagine that a 12 month referral could lead to greater weight loss and more long term changes than a 12 week programme, and that this could mean less weight regain. However, the likely increased effect will come at a higher cost, leaving the question 'What is the more cost-effective option?'. This is precisely what this study seeks to examine. We also want to uderstand more about the patient experience of weight loss treatment. Previous research has shown that many adults with overweight and obesity do not consider this to be a medical problem and this may influence their attitudes to receiving treatment through the NHS. By improving our understanding of attitudes and experience of treatment, we can improve the way weight management is provided by the NHS.
In our trial, 1200 adults with overweight and obesity will be identified by their GP and recruited by the research team. The research team will randomly assign participants to one of three treatment groups - a 12 session referral to a commercial provider, a 12 month referral to a commercial provider, or a 'brief intervention' (standard information about how to lose weight and weighing at follow up). We will follow participants up at 3 months, 12 months and 24 months (1 year after treatment has finished) to compare the amount of weight lost by participants in each group. We will also look at how many participants in each group lose an amount of weight that is associated with significant health improvements. We will use this and other data collected during the trial to examine which treatment option offers the best value for money. This will be examined over the short term (the duration of the trial) and the longer term, using long term modelling of anticipated health changes and associated costs. We will also interview a subset of participants to gain a more holistic view of the patient experience and to explore their attitudes to weight loss treatment and NHS-commercial partnerships.
This research will provide important information to GPs and NHS treatment commissioners about which treatment option is most effective and which offers best value for money. Trial results and findings from interviews will help inform future decisions about NHS-commercial partnership
Previous research has shown that referring a patient for 12 sessions with a commercial weight loss provider can produce an amount of weight loss which has significant health benefits. These referral packages are offered to the NHS at a discounted price, however no studies have formally evaluated the cost-effectiveness of this approach. This study will examine whether the money spent on treatment is worthwhile when we consider the effect of improved health for patients and also potential cost savings on treatments for weight-related illness. But weight regain is common after weight loss treatment stops and it may be that 12 weeks is not long enough to develop long term changes in behaviour. It is not hard to imagine that a 12 month referral could lead to greater weight loss and more long term changes than a 12 week programme, and that this could mean less weight regain. However, the likely increased effect will come at a higher cost, leaving the question 'What is the more cost-effective option?'. This is precisely what this study seeks to examine. We also want to uderstand more about the patient experience of weight loss treatment. Previous research has shown that many adults with overweight and obesity do not consider this to be a medical problem and this may influence their attitudes to receiving treatment through the NHS. By improving our understanding of attitudes and experience of treatment, we can improve the way weight management is provided by the NHS.
In our trial, 1200 adults with overweight and obesity will be identified by their GP and recruited by the research team. The research team will randomly assign participants to one of three treatment groups - a 12 session referral to a commercial provider, a 12 month referral to a commercial provider, or a 'brief intervention' (standard information about how to lose weight and weighing at follow up). We will follow participants up at 3 months, 12 months and 24 months (1 year after treatment has finished) to compare the amount of weight lost by participants in each group. We will also look at how many participants in each group lose an amount of weight that is associated with significant health improvements. We will use this and other data collected during the trial to examine which treatment option offers the best value for money. This will be examined over the short term (the duration of the trial) and the longer term, using long term modelling of anticipated health changes and associated costs. We will also interview a subset of participants to gain a more holistic view of the patient experience and to explore their attitudes to weight loss treatment and NHS-commercial partnerships.
This research will provide important information to GPs and NHS treatment commissioners about which treatment option is most effective and which offers best value for money. Trial results and findings from interviews will help inform future decisions about NHS-commercial partnership
Technical Summary
The prevalence of adult overweight and obesity and the associated burden of disease put increasing pressure on NHS resources. There is urgent need for treatment options that are clinically and cost-effective and deliverable at scale in primary care. Recent trials demonstrate the acceptability and short term efficacy of primary care referral to a commercial weight loss provider. NHS commissioners now need information on the optimal duration of intervention and the longer term outcomes and cost effectiveness of such treatment to give best value for money. The proposed 2 year randomised controlled trial will evaluate the clinical and cost effectiveness of 3 weight loss interventions that can be delivered in primary care (referral to a commercial weight loss provider (Weight Watchers; WW) for 12 weeks; referral to WW for 12 months; or a brief intervention that consists of standard information and periodic weighing with feedback). Participants will be 1200 adults (BMI >28kg/m2; Age>18years) identified by their GP as likely to benefit from weight loss. Participants attend assessments with the research team at 0, 3, 12 and 24 months. Main outcomes for evaluation of clinical effectiveness will be changes in weight, fat mass, and blood pressure, and the primary analysis will be an intention to treat analysis of differences between treatments. Secondary analyses will include a completers only analysis and the proportion of all participants and completers losing 5% or more of initial weight. Data will also be collected on quality of life and health care usage over the two year period to evaluate cost-effectiveness. A within-trial and long term cost-effectiveness analysis will be conducted from an NHS perspective. Qualitative methods will be used to examine experiences of patients and practitioners involved in the trial and their attitudes to NHS partnerships with the commercial sector. Findings will help practitioners and commissioners make decisions about treatment provision.
Planned Impact
It is anticipated that by improving the evidence base for primary care weight loss treatment, findings will help improve weight loss treatment provision in the UK NHS, thus having a direct benefit for patient and population health and quality of life. The impact of this study is not limited to the UK. Overweight and obesity is a global problem and these data will also inform international interest in obesity treatment provision and contribute to the UK role as a leader in obesity treatment and primary health care research. However, NHS commissioners will benefit from robust evidence on the effectiveness and cost-effectiveness of commercial weight loss treatment, enabling them to make better informed decisions about treatment provision and the allocation of resources. The trial should also inform debate about the nature of NHS-commercial partnerships at a national level and will be relevant to discussions around the Government Responsibility Deal for public health. Practitioners will benefit from better evidence on which to base treatment decisions, and in time will perhaps benefit from better choice and availabity of treatment options and referral pathways. Findings should also illuminate the optimal implementation of treatment provision. Disseminating the findings of this study will provide opportunities to open up a dialogue with the public on the role of health professionals and commercial providers in weight management.
The commercial treatment provider involved in the research may benefit from heightened profile and increased business through the NHS. Other commercial treatment providers may also benefit from a stronger evidence base for commercial referral and findings could potentially increase collaborative relationships with the National Health Service. We hope that this trial will strengthen the precedent for robust, independent evaluation of commercial programmes, encouraging responsible involvement of commercial companies in scientific research.
The research team will all benefit from the opportunity to collaborate on this research and share knowledge and expertise across research centres. Involvement in the trial will offer a platform for developing new interdisciplinary research networks, with the intention that these will lead to further research collaborations. This grant will specifically improve the career trajectories of the Principal Investigator and the Trial Manager. The Principal Investigator has experience of running similar trials and coordinating scientific studies. As PI on this grant she will be able to formally demonstrate her abilities as an independent researcher, with mentoring from Dr Jebb as line manager and coapplicant. The Trial Manager has received considerable training in the necessary skills of trial management and already has some experience of trial management. This study will provide a challenging but nurturing environment in which to put these skills into practice and give her the experience and further training/mentoring needed for her to progress to the next grade and make a transition from research support to trial manager.
The commercial treatment provider involved in the research may benefit from heightened profile and increased business through the NHS. Other commercial treatment providers may also benefit from a stronger evidence base for commercial referral and findings could potentially increase collaborative relationships with the National Health Service. We hope that this trial will strengthen the precedent for robust, independent evaluation of commercial programmes, encouraging responsible involvement of commercial companies in scientific research.
The research team will all benefit from the opportunity to collaborate on this research and share knowledge and expertise across research centres. Involvement in the trial will offer a platform for developing new interdisciplinary research networks, with the intention that these will lead to further research collaborations. This grant will specifically improve the career trajectories of the Principal Investigator and the Trial Manager. The Principal Investigator has experience of running similar trials and coordinating scientific studies. As PI on this grant she will be able to formally demonstrate her abilities as an independent researcher, with mentoring from Dr Jebb as line manager and coapplicant. The Trial Manager has received considerable training in the necessary skills of trial management and already has some experience of trial management. This study will provide a challenging but nurturing environment in which to put these skills into practice and give her the experience and further training/mentoring needed for her to progress to the next grade and make a transition from research support to trial manager.
Publications

Ahern AL
(2014)
Weight loss referrals for adults in primary care (WRAP): protocol for a multi-centre randomised controlled trial comparing the clinical and cost-effectiveness of primary care referral to a commercial weight loss provider for 12 weeks, referral for 52 weeks, and a brief self-help intervention [ISRCTN82857232].
in BMC public health


Ahern AL
(2016)
Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care.
in The British journal of general practice : the journal of the Royal College of General Practitioners

Allen JT
(2015)
Experiences of a commercial weight-loss programme after primary care referral: a qualitative study.
in The British journal of general practice : the journal of the Royal College of General Practitioners
Description | Briefing for DH Permanent Secretary |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | Informed development of government obesity strategy |
Description | Evidence/ Interview for NIHR Dissemination Centre |
Geographic Reach | National |
Policy Influence Type | Influenced training of practitioners or researchers |
URL | http://www.dc.nihr.ac.uk/highlights-and-reviews/obesity-in-men/feature-pages/what-motivates-men-to-l... |
Description | Invited lecture and run table discussion with Department of Health, Canberra, Australia |
Geographic Reach | Australia |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | Consideration given to possibility of implementing new schemes to offer behavioural weight management interventions as central part of new chronic disease management pathway |
Description | National Diabetes Prevention Programme Advisory Group |
Geographic Reach | National |
Policy Influence Type | Participation in a advisory committee |
Impact | Development of a national scheme for prevention of diabetes |
Description | No 10 Round-table on obesity |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | Discussions informed development of obesity strategy |
Description | Public Health England Obesity Review Board |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | Public health England Obesity Priority Programme Board |
Geographic Reach | National |
Policy Influence Type | Participation in a advisory committee |
Description | Funding for collection and analysis of blood samples |
Amount | £186,000 (GBP) |
Organisation | Weight Watchers International |
Sector | Private |
Country | United Kingdom |
Start | 09/2013 |
End | 09/2015 |
Description | Liverpool Industry CASE Studentship |
Amount | £60,000 (GBP) |
Organisation | Science and Technologies Facilities Council (STFC) |
Department | Industrial Case Studentship |
Sector | Public |
Country | United Kingdom |
Start | 10/2012 |
End | 09/2015 |
Description | EMA CASE Studentship (Liverpool) |
Organisation | University of Liverpool |
Department | School of Psychological Sciences |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Contribution to study design and funding application. Co-supervision of student. |
Collaborator Contribution | Led study design and funding application. Primary supervision of student. |
Impact | NWDTC ESRC CASE Studentship at University of Liverpool |
Start Year | 2013 |
Description | BBC Horizon Series: What's the Right Diet for You? |
Form Of Engagement Activity | A broadcast e.g. TV/radio/film/podcast (other than news/press) |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | BBC2 horizon Series - 3 x 1h episodes, later also shown on BBC Worldwide Accompanying e-book Webinar and Live post programme chat |
Year(s) Of Engagement Activity | 2015 |
URL | http://www.bbc.co.uk/programmes/p02ddsd9 |
Description | Institute of Child Health Seminar series |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | Talk on weight management in primary care |
Year(s) Of Engagement Activity | 2014 |
Description | Liverpool Postgraduate Conference |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Postgraduate students |
Results and Impact | Invited Keynote presentation at Liverpool School of Psychology Postgraduate Research Student Conference, attended by 25 PhD canditates and supervisors. Led to questions and discussion about the research and attendees reported an increased interest in doing multi-disciplinary research in public health. Feedback from several students that presentation had inspired them to think about how their work could be applied to public health problems and to consider a career in applied research. |
Year(s) Of Engagement Activity | 2013 |
Description | Oxford Brazil Diabetes Symposium |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Talk on Weight Management in Primary Care |
Year(s) Of Engagement Activity | 2015 |
Description | Participant Newsletters |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Study participants or study members |
Results and Impact | Participants are all sent newsletters which gave them more information about the trial, who was taking part, the trial team, the goals of the research, and preliminary results. This increased participant retention in the WRAP trial and encouraged participants to stay engaged in research. Participant retention in the WRAP trial increased and some participants attributed this to the newsletter. |
Year(s) Of Engagement Activity | 2013,2014,2015,2016 |
Description | Presentation at PCRN National Team Meeting |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | Yes |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Shared experience of recruitment phase of trial with PCRN members, GPs and practice staff from across the country as part of a workshop aimed at sharing best practice and improving service provision. Led to increased interest in participating in this type of research, and sharing of ideas to make it easier to conduct this type of research. Prompted considerable discussion on the challenges of conducting obesity research in primary care and what the PCRN might do to try and overcome such challenges. Several network members expressed interest in participating in this kind of research in the future. |
Year(s) Of Engagement Activity | 2013 |
Description | Richard Doll Seminar Series |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Other audiences |
Results and Impact | Talk on "New evidence from trials to inform the management of obesity in routine care" Audience of about 150 In following week, two doctors spontaneously reported that they had changed their practice and made a brief intervention for weight management with a patient |
Year(s) Of Engagement Activity | 2016 |