Author: Joshua Clamp / Editor: Shane McAuliffe
A recent article published in BMJ Nutrition, Prevention & Health tested the efficacy of a remotely delivered weight management service in a primary care setting.
Reference: Walker L, Smith N, Delon C. Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care. BMJ Nutrition, Prevention & Health 2021;bmjnph-2020-000219. Doi: 10.1136/bmjnph-2020-000219
Background
Obesity and related metabolic diseases, including Type 2 Diabetes and cardiovascular disease, remain a major public health challenge in the UK. Some 63% of adults in England are overweight or obese, which has been associated with increased risk of Covid-19 complications (PHE, 2020). Not only this, but national lockdowns as a result of Covid-19 have themselves contributed to weight gain (ZOE Covid Study, 2020).
In the UK, weight management services have traditionally involved community-based, group lifestyle programmes delivered in a face-to-face format. However, the arrival of national lockdowns in England meant that service providers had no choice but to rapidly shift to virtual delivery and say goodbye to the traditional setting. With lockdowns now lifted in the UK, some weight management services are once again being delivered face-to-face.
However, many services in primary care settings remain remote due to the increased vulnerability of primary care patients. Limited research exists on the efficacy of remotely delivered weight management services in such contexts. Developing an understanding of how these services can be optimised for maximum efficacy in these patients is therefore important.
The intervention
This study explored the efficacy of a remotely-delivered, community-based group weight loss intervention in a primary care setting. The intervention involved a weight loss and health promotion programme delivered as part of an initiative from the registered UK charity Public Health Collaboration. This programme, officially titled the ‘Low Carb Real Food Lifestyle Programme’, involved six 90-minute sessions conducted across ten weeks and was delivered via Zoom. Participants also had access to optional extra support through private social media groups. The patients were recruited from a four-practice, 32000-patient primary care network in Hampshire, UK. Participants were adults with T2D, pre-diabetes or who had been advised to lose weight, plus those living with or caring for someone in one of these categories.
Evidence points towards the use of multiple healthy lifestyle behaviours in reducing risk of mortality (Loef & Walach, 2012). As such, this programme included education on several important lifestyle factors, including diet, physical activity, sleep, stress management, gut health and behaviour change. The programme was designed to provide a foundational understanding nutrition, physiology, and behaviour change to help participants understand, engage in and feel some control over their health.
Traditional weight loss programmes often involve a focus on caloric restriction and/or may utilise structured meal plans. This intervention, however, did not adopt a calorie-focused approach. Instead, it included an element of carbohydrate restriction, which has reported benefits of reduced blood pressure and weight loss in primary care patients and anecdotal improvements in wellbeing (Unwin et al., 2020). Participants of this programme were encouraged to restrict sugar, processed foods and starchy carbohydrates such as bread, pasta, rice and potatoes and to focus on eating minimally processed foods to satiety. An individualised approach was encouraged to ensure that preferences and demands associated with each participant’s lifestyle were met, and to make changes at their own pace. This advice was provided alongside resources including a one-page guide to low-carbohydrate eating and lists of foods to enjoy and avoid, as well as recipe suggestions.
Measurements
A range of measures were used to assess the efficacy of this intervention. The primary outcome measures were weight loss, changes in body mass index, waist circumference, and mental wellbeing, measured using the Warwick Edinburgh Mental Wellbeing Scale. Secondary outcomes were changes in blood pressure and blood glucose control. Subjective outcomes regarding participant experience were also recorded, collected via a questionnaire. Most data were collected prior to the first session and after the last session, however participants were encouraged to monitor and record their weight and waist circumference at regular intervals. The design of this study meant there was no control group, and instead authors chose to use a pre-post comparison.
Results
30 people attended the information session, however only 20 completed the programme and had data valid for analysis. Of these 20, 17 (85%) were female and the majority (60%) were classified as having obesity. All participants were over 40 years old.
All primary outcome measures improved significantly, with participants achieving a mean weight loss of 5.8kg, representing a mean weight loss of 6.5%. Mean BMI reduced by 2 kg/m2, and mean waist circumference reduced by 5.2 cm, whilst mental wellbeing scores also increased.
Blood pressure and blood glucose levels also improved, and participants on insulin reduced their dosage. Feedback from participants also reflected the positive objective outcomes, and described improved confidence, increased positive feelings about health, and better energy overall. Furthermore, majority (78%) of participants were confident in their ability to maintain their changes, and over 80% said that that the experience via Zoom worked well. Finally two-thirds of feedback survey respondents reported losing weight without hunger and with reduced food cravings.
Strengths, limitations and points for consideration
The study had a small sample size, and no control group was used. Additionally, the sample was not randomised, increasing risk of selection bias. Furthermore, much of the data were self-reported, which introduces reporting bias. Long-term follow up was not possible, thus it cannot be said whether such an intervention had a lasting impact on the measured outcomes.
The ability of this paper to provide evidence or the efficacy of carbohydrate restriction as an independent driver of weight loss and health improvement is limited. The study did not have the capacity to reliably measure carbohydrate intake of participants, and so exact compliance was unknown. Furthermore, as the intervention used multiple approaches, the positive results cannot be pinned directly to the carbohydrate restriction.
Authors also highlighted possible confounding factors that could have affected outcomes, such as the COVID-19 pandemic itself and the drastic changes it imposed on our daily lives. This may have had a positive confounding effect due to there being more time to cook, make meals from scratch, and exercise, as well as fewer social opportunities that may challenge compliance. On the other hand, increased stress, as well as reduced access to food retailers and exercise venues may have had a negative influence.
Despite these limitations, the results observed were very positive, and in line with those from similar interventions. This intervention clearly demonstrated the potential for remotely delivered weight management services in primary care patients.
One final factor for consideration is the different demands of remote vs face-to-face delivery, and how these demands translate to differing accessibility for different individuals. For example, whilst it is clear that remote delivery can offer logistic, financial and time benefits, it also requires access to and understanding of certain technologies. Patients from different socioeconomic backgrounds may therefore have greater access to and preference of different delivery formats. This is an issue that should be considered when developing and delivering future remote weight management services.
Key takeaways
This study represents one of the first evaluations of a remotely delivered group-based weight loss or health promotion programme in primary care patients. Results support the notion that an effective health promotion programme can be delivered to a range of participants without the need for premises or meeting in person. This provides promise for addressing obesity and related metabolic conditions in novel ways.
It also supports evidence that the provision of information and guidance on a range of dietary factors, including a focus on carbohydrate restriction, can lead to significant changes in weight and other chronic disease risk factors. However, as discussed due to the nature of the study and measuring capacity of the researchers, exact carbohydrate intake could not be measured. So whilst carbohydrates were estimated to have decreased, authors suggest that the advice to eliminate sugar and restrict starches and ultra-processed foods was effective in contributing to the observed benefits. Thus, this guidance could provide a realistic, acceptable alternative to strict carbohydrate restriction or carbohydrate counting. It is worth noting that this advice is also common across a number of dietary approaches for weight loss and overall health improvement.
Moreover, this supports the evidence that the use of a holistic approach, targeting both the education and application of multiple features of healthy lifestyles, including nutrition, physical activity, stress management, sleep, and behaviour change, can be efficacious in achieving weight loss.
References & further reading
Covid Symptom Study. Has lockdown influenced our eating habits? the silent pandemic: how lockdown is affecting our future health. 2020. Available: https://covid.joinzoe.com/post/lockdown-weight-gain#:~:text=The%20factors%20that%20may%20have,less%20healthy%20diet%20(19%25)
Loef M, Walach H. The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Prev Med. 2012;55(3):163-70. Doi: 10.1016/j.ypmed.2012.06.017. Epub 2012 Jun 24. PMID: 22735042.
Public Health England. Excess weight and COVID-19. insights from new evidence 2020. Available: https://www.gov.uk/government/publications/excess-weight-and-covid-19-insights-from-new-evidence
Unwin D, Khalid AA, Unwin J, Crocombe D, Delon C, Martyn K, Golubic R, Ray S. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutrition, Prevention & Health 2020;3(2):285-294. Doi: 10.1136/bmjnph-2020-000072. PMID: 33521540; PMCID: PMC7841829.
Walker L, Smith N, Delon C. Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care. BMJ Nutrition, Prevention & Health 2021;bmjnph-2020-000219. Doi: 10.1136/bmjnph-2020-000219.