Not All Weight-Loss Programs Follow Guideline Recommendations
Commentary by Kimberly A. Gudzune, MD, MPH and J. Michael Gonzalez-Campoy, MD, PhD, FACE
In the United States (US), two-thirds of adults suffer from overweight or obesity. Not surprisingly, a wide variety of weight loss programs are in the market place. Patients have to research and decide which weight loss program is right for them.
A recent study looked at 191 different weight loss programs located in the Maryland-Washington, DC-Virginia region to see how well these programs adhered to consensus recommendations —only 1% closely followed guidelines. Ninety-one percent (91%) of weight loss programs had a low adherence to guideline recommendations, according to information provided on program websites.
A wide scope of important details simply were unavailable if someone tried to find them online, like the program’s intensity level, diet regimen, physical activity, and use of behavioral strategies. According to Kimberly A. Gudzune, MD, MPH, an assistant professor of medicine at Johns Hopkins University in Baltimore, Maryland, this is a significant finding. It illustrates the realities patients face when they are trying to choose a weight loss program—information is simply sparse.
The Best Weight Loss Program, Guideline-Recommended
In 2013, the American Heart Association, American College of Cardiology, and the Obesity Society (AHA/ACC/OBS)1 published the recommended criteria for an effective, comprehensive lifestyle intervention program. “The guidelines are critical in this respect because they help patients and doctors sort through the options and find the most beneficial weight loss program out there,” said Dr. Gudzune.
A comprehensive program* should feature:
- A moderately-reduced caloric meal plan
- A regimen for increased physical activity
- A behavioral therapy strategy
*Pharmacotherapy also may be part of a weight loss strategy2
However, most doctors learn to treat obesity after they have graduated from training. “When we do studies looking at recording encounters between patients and physicians, a lot of times the physician’s advice is a little bit nonspecific or basic.” So the guidelines help by providing a standardized framework for the right weight loss program, said Dr. Gudzune.
A majority (75%) of the programs endorsed some form of dieting, but it was impossible to find out the diet type. Many programs (57%) described some type of exercise, but only 3% met the recommended goal: 150 minutes or more of moderate physical activity every week. The usage of behavioral strategies, the prescription of FDA-approved medications, and even the intensity of the program—all of these parameters were either underreported or missing from the programs.
This was concerning considering 29% of the programs were physician-supervised, which could mean some physicians were working directly with patients through these programs but not working within the recommendations of professional guidelines.
Unfortunately, patients may have to make a phone call to the program to get the details they need, but this is not a guaranteed solution. Only 27% of the programs had their representatives agree to a telephone interview, and 40% of the time, the information provided over the phone made the websites less reliable.
For instance, 21% of the programs endorsed supplements during the phone interview, while no mention of supplements was made through the website. Dietary supplements, nutraceuticals, and other products not approved by the FDA should be discussed between a doctor and patient, but if patients are not aware of these products from the outset, they could be left out of the conversation.
“I think when doctors talk with patients, cost should also be something they discuss, because it is a very relevant issue for all patients,” especially considering how expensive some weight loss programs can be, another detail not popularly advertised. It can be difficult for low income patients to deal with this issue. Weight loss programs are essentially an out-of-pocket expense, unless a patient has the benefit of a flexible spending account through their employment.
Consumer Power: Making the Call
Ultimately, patients looking for the right weight loss program are equivalent to customers looking for the right product, so getting details is a necessity. While the Federal Trade Commission (FTC) does regulate the claims made by weight loss and dietary supplement companies,3 there could be a need to expand this requirement to correspond with professional guidelines. After all, 19% of the programs that agreed to phone interview actually were guideline concordant.
However, the power likely lies with the consumer to prompt better advertising, perhaps even better overall quality in the programs. If doctors encourage patients to call and ask for such details, companies may be more proactive about updating their websites with guideline-concordant information. Then, medical associations could step in, offering a “seal of approval” to help guide patients to the most guideline-adherent programs.
“That might be a faster way to verify and provide some credibility and really highlight those programs that are doing the good work because there are some out there that really should be recognized and used by folks, but given the sea of information that is out there, they can be really hard for people to find,” said Dr. Gudzune.
Commentary by J. Michael Gonzalez-Campoy, MD, PhD, FACE
J. Michael Gonzalez-Campoy, MD, PhD, FACE, is the Medical Director and Chief Executive Officer of the Minnesota Center for Obesity, Metabolism and Endocrinology in Eagan, Minnesota. As senior editor of the EndocrineWeb obesity section, Dr. Gonzalez-Campoy offered his own commentary on the new research.
The American Board of Obesity Medicine (ABOM) was established in 2011 to provide certification of physicians with a focus of practice in obesity medicine. Diplomates of the ABOM are recognized experts in the field of obesity medicine. Patients can find these physicians through the website of the ABOM.
The current paper has two major pitfalls. The first major pitfall is that this paper identified commercial weight loss programs, most of which have a service or product to sell, and tried to apply clinical practice guidelines to them. Since most of these centers are not formal medical practices, they would not be expected to adhere to clinical practice guidelines.
The second major pitfall is the authors chose one particular clinical practice guideline, which according to its authors, was outdated before it was even finalized. The creation of this guideline began before multiple options for pharmacotherapy entered the US market, so the guideline does not include recommendations for the pharmacotherapy of obesity.
With the epidemic of overweight and obesity in this country, two-thirds of Americans will seek help managing their weight. The point is well taken that there is too much commercialism—selling products with a promise of unrealistic achievements. Since obesity is a chronic disease, patients are best served seeking the expertise of clinicians recognized by the ABOM.
Response by Kimberly A. Gudzune, MD, MPH
Assistant Professor of Medicine
Johns Hopkins University
Dr. Gudzune responded to Dr. Gonzalez-Campoy’s comments about the study’s usage of the AHA/ACC/TOS guidelines, stating that the guidelines are considered the “foundation of any program,” regardless if pharmacotherapy is utilized or not. In the study, only 15% of the programs reported using FDA-approved medications.
“Weight loss medications can be a complimentary strategy to enhance these key elements for programs that are physician supervised—in fact, this strategy is how these other guidelines recommend that they be used,” said Dr. Gudzune.
Dr. Gudzune, et al decided not to use other guidelines that mention pharmacotherapy practices, such as the ones provided by the Obesity Medicine Association (formerly, American Society of Bariatric Physicians) and the Endocrine Society, because the majority of the programs analyzed in the study were not physician-supervised, which meant they could not legally prescribe FDA-approved medications.
Also, medications for weight loss are not indicated for all patients, as they can have side effects and risks. Many of these drugs, like lorcaserin or phentermine/topiramate, can be expensive and not covered by the patient’s insurance, which could make them inaccessible to some patients, said Dr. Gudzune.
“Requiring weight loss medications as a key element would have unfairly penalized quality programs that do not have a physician involved, which would be a disservice to the field. Physician supervised programs are not the only potential pathway to evidence-based weight loss.”
Study coauthor Benjamin Bloom, MD, was supported by the Medical Student Research Program in Diabetes at Johns Hopkins University – University of Maryland Diabetes Research Center from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Gudzune was supported by a career development award from the National Heart, Lung, and Blood Institute.
March 16, 2016