Popular Diets and Commercial

Weight Loss Programs

Kimberly Gudzune, MD MPH
Assistant Professor of Medicine
Welch Center for Prevention, Epidemiology & Clinical Research
Johns Hopkins Digestive Weight Loss Center

February 24, 2016

1
Disclosures

No personal conflicts of interest to

disclose

2
 AHA/ACC/TOS Weight
Management Guidelines
3 to 5% weight loss initial goal
Improves glucose and triglycerides
Prevents development of diabetes
5 to 10% weight loss
Improves blood pressure
Lowers LDL-c and raises HDL-c
Reduces need for medications

Jensen & colleagues. Circulation. 2014; 129:S102-38.

 AHA/ACC/TOS Weight
Management Guidelines
Enroll in a high-intensity
comprehensive lifestyle program for
at least 6 months
Encourages a lower-calorie diet and
increased physical activity by using
behavioral strategies
High-intensity 14 sessions in 6 months

Jensen & colleagues. Circulation. 2014; 129:S102-38.

Patients have greater weight
loss success if their clinician
Higher ratings of the
helpfulness of the
doctor in a program
greater weight loss
Patients who discussed
weight loss with their
doctor & did not
perceive judgment from
her/him are more likely
to achieve a 10%
weight loss
Figure reproduced with permission from author. Prev Med. 2014, 62: 103-7.

Bennett & colleagues. Patient Educ Couns. 2015; 98:1099-105. Gudzune & colleagues. Prev Med. 2014; 62: 103-7. 5
 Are these programs available
in the community?
Only 19% of weight loss
programs in community
have high concordance
with guidelines
More difficult to identify
guideline concordant
programs using website
information alone

Table and figure reproduced with permission from author. Obesity (Silver Spring). 2016.

Bloom & colleagues. Obesity (Silver Spring). 2016 (in press). 6

 AHA/ACC/TOS Weight
Management Guidelines
Some commercial-based programs that
provide a comprehensive lifestyle
intervention can be prescribed as an
option for weight loss, provided there is
peer-reviewed published evidence of
their safety and efficacy

Which ones have this evidence???

Jensen & colleagues. Circulation. 2014; 129:S102-38.

Copyright American College of Physicians. All rights reserved.
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Table Legend:
Programs excluded because they lacked a support component, such as group support, coaching, or online group forum, unless indicated as follows: * Program
inactive, not available in U.S., or only available in single state. Program focused on food addiction. Primary program focus is wellness or cardiovascular risk
reduction. Residential program. || Lacked dietary component.

Copyright American College of Physicians. All rights reserved.

Ornish, Volumetrics, Zone
Weight loss results
Programs did not meet criteria for inclusion in
systematic review
Meta-analysis found significant weight loss
differences relative to no diet at 12 months
Ornish has 6.6 kg more weight loss (95% CI: 3.4, 9.8)
Volumetrics has 6.0 kg more weight loss (95%CI: 0.6, 11.5)
Zone has 6.0 kg more weight loss (95% CI: 3.2, 8.7)

Johnston & colleagues. JAMA. 2014; 312:923-33. 10

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Figure Legend:
Summary of evidence search and selection. RCT = randomized, controlled trial. *Trials with ineligible study designs (e.g., retrospective case series or RCTs <12 wk
in duration) or ineligible programs (e.g., not available in the United States). Used medications or supplements; modified specifically for the study; unavailable in
the United States; or available only to special populations, such as active-duty military personnel or veterans. Prospective case series or RCTs without an eligible
comparator group of 12 mo duration that reported harms.

Copyright American College of Physicians. All rights reserved.

 Popular programs with
no eligible RCTs identified
Alere Weight Talk iDiet
Best Life Jillian Michaels
Body for Life LA Weight Loss
Calorie King My Fitness Pal
Curves P.I.N.K. Method
Daily Burn Robard
Dukan Diet South Beach Diet
Fat Secret Spark People
Fit Day Taking off pounds sensibly
Flat Belly Diet (TOPS)
Ideal Protein Traineo

Gudzune & colleagues. Ann Intern Med. 2015; 162:501-512.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
2.6% more
than control at
12 months

12-month
results mixed
WW vs
counseling

Figure Legend:
Difference in mean percentage of weight change between commercial programs that dominate the market share (Weight Watchers, Jenny Craig, and Nutrisystem)
and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the
percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; LC = low-carbohydrate version of program; NR = not reported; P = commercial
program group; T = telephone-based program; WW = Weight Watchers. *Results reported in >1 article. Results from completers' analysis.

Copyright American College of Physicians. All rights reserved.

Weight Watchers
Weight loss results
Weight Watchers has significantly greater
weight loss than no diet
7.3 kg more at 6 months (95%CI: 5.3, 9.3)
5.9 kg more at 12 months (95% CI: 3.9, 8.1)

Johnston & colleagues. JAMA. 2014; 312:923-33. 15

Weight Watchers
12M CVD Risk Factors
Few trials reported CVD risk factors
Blood pressure
No significant change in SBP relative to control
Lowers DBP 0.6 to1.8 mmHg more than control
Lipids
Lowers LDL-c 3.5 mg/dL more than control
Raises HDL-c 1.2 mg/dL more than control
Glycemia
No significant difference in glucose relative to control

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 16
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

 Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
4.9% more
than
comparator at
12 months

Figure Legend:
Difference in mean percentage of weight change between commercial programs that dominate the market share (Weight Watchers, Jenny Craig, and Nutrisystem)
and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the
percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; LC = low-carbohydrate version of program; NR = not reported; P = commercial
program group; T = telephone-based program; WW = Weight Watchers. *Results reported in >1 article. Results from completers' analysis.

Copyright American College of Physicians. All rights reserved.

Jenny Craig
Weight loss results
Jenny Craig has significantly greater weight
loss than no diet
5.8 kg more at 6 months (95%CI: 3.3, 8.3)
6.4 kg more at 12 months (95% CI: 3.0, 9.7)

Johnston & colleagues. JAMA. 2014; 312:923-33. 19

Jenny Craig
12M CVD Risk Factors
Few trials reported CVD risk factors
Blood pressure
Counseling lowers SBP 1.0 to 3.0 mmHg more than
Jenny Craig
Effects on DBP mixed
Lipids
Counseling lowers LDL-c 2.0 to 13.0 mg/dL more than
Jenny Craig
Raises HDL-c up to 5.0 mg/dL more than counseling
Glycemia
Lowers A1c 0.4 to 0.8% more than counseling among
patients with DM
Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 20
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

 Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
3.8% more than
comparator in
short-term

No long-term
studies

Figure Legend:
Difference in mean percentage of weight change between commercial programs that dominate the market share (Weight Watchers, Jenny Craig, and Nutrisystem)
and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the
percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; LC = low-carbohydrate version of program; NR = not reported; P = commercial
program group; T = telephone-based program; WW = Weight Watchers. *Results reported in >1 article. Results from completers' analysis.

Copyright American College of Physicians. All rights reserved.

Nutrisystem
Weight loss results
Nutrisystem has significantly greater weight
loss than no diet
7.4 kg more at 6 months (95%CI: 4.6, 10.2)

Johnston & colleagues. JAMA. 2014; 312:923-33. 23

Nutrisystem
Short-Term CVD Risk Factors
Few trials reported CVD risk factors
Blood pressure
Lowers SBP 4.7 mmHg more than counseling at 6
months
No significant between-group difference in DBP
Lipids
No significant between-group differences in LDL-c or
HDL-c at 6 months
Glycemia
Lower A1c 0.3% more than counseling among pateints
with DM at 6 months

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 24
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
8.1% more
than
comparator in
short-term

No long-term
studies

Figure Legend:
Difference in mean percentage of weight change between commercial programs that use very-low-calorie or low-calorie meal replacements (HMR, Medifast, and
OPTIFAST) and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects
the percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; HMR = Health Management Resources; NR = not reported; P = commercial program
group; T = telephone-based program. *Results from completers' analysis. Trial reported median percentage of difference in weight change rather than mean.
Intervention was low-calorie (1200 to 1500 calories daily) during weight loss phase.

Copyright American College of Physicians. All rights reserved.

HMR
Short-Term CVD Risk Factors
One trial reported CVD risk factors
Blood pressure
No trials reported BP
Lipids
No significant between-group differences in LDL-c at 6
months
No trials reported HDL-c
Glycemia
Lowers glucose 10.4 mg/dL more than counseling at 6
months

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 27
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose 5.6%
more than
counseling at 4
months

No significant
difference at 9
months

Figure Legend:
Difference in mean percentage of weight change between commercial programs that use very-low-calorie or low-calorie meal replacements (HMR, Medifast, and
OPTIFAST) and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects
the percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; HMR = Health Management Resources; NR = not reported; P = commercial program
group; T = telephone-based program. *Results from completers' analysis. Trial reported median percentage of difference in weight change rather than mean.
Intervention was low-calorie (1200 to 1500 calories daily) during weight loss phase.

Copyright American College of Physicians. All rights reserved.

Medifast
Short-Term CVD Risk Factors
One trial reported CVD risk factors
Blood pressure
No significant between-group difference in SBP at 9
months
Lowers DBP 4.6 mmHg more than counseling
Lipids
No significant between-group differences in LDL-c or
HDL-c at 9 months
Glycemia
No trials reported glucose or A1c

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 30
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
4% more than
counseling in
short-term

No significant
difference
beyond 12
months

Figure Legend:
Difference in mean percentage of weight change between commercial programs that use very-low-calorie or low-calorie meal replacements (HMR, Medifast, and
OPTIFAST) and comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects
the percentage of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with
diabetes mellitus; GEN = general population of overweight and obese patients; HMR = Health Management Resources; NR = not reported; P = commercial program
group; T = telephone-based program. *Results from completers' analysis. Trial reported median percentage of difference in weight change rather than mean.
Intervention was low-calorie (1200 to 1500 calories daily) during weight loss phase.

Copyright American College of Physicians. All rights reserved.

OPTIFAST
Short-Term CVD Risk Factors
One trial reported CVD risk factors
Blood pressure
Lowers SBP and DBP 3.0 mmHg more than counseling
at 6 months
Lipids
Counseling lowers LDL-c 8.9 mg/dL more than
OPTIFAST at 6 months
No between-group difference in HDL-c
Glycemia
Lowers A1c 0.3% more than counseling among patients
with DM at 6 months

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 33
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Results mixed
Slimfast vs
comparators

Figure Legend:
Difference in mean percentage of weight change between self-directed commercial programs (Atkins, The Biggest Loser Club, eDiets, Lose It!, and SlimFast) and
comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the percentage
of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with diabetes mellitus;
GEN = general population of overweight and obese patients; NR = not reported; P = commercial program group. *Results reported in >1 article. Results from
completers' analysis. Overall attrition at time point.

Copyright American College of Physicians. All rights reserved.

Slimfast
Short-Term CVD Risk Factors
Few trials reported CVD risk factors
Blood pressure
Lowers SBP and DBP 3.0 mmHg more than counseling
at 6 months
Lipids
Counseling lowers LDL-c 8.9 mg/dL more than
OPTIFAST at 6 months
No between-group difference in HDL-c
Glycemia
No significant between-group difference in A1c change
among patients with DM at 6 months
Little between-group difference in glucose
Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 36
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose at least
0.7% more
than
comparator in
short-term

Varying long-
term weight
loss results

Figure Legend:
Difference in mean percentage of weight change between self-directed commercial programs (Atkins, The Biggest Loser Club, eDiets, Lose It!, and SlimFast) and
comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the percentage
of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with diabetes mellitus;
GEN = general population of overweight and obese patients; NR = not reported; P = commercial program group. *Results reported in >1 article. Results from
completers' analysis. Overall attrition at time point.

Copyright American College of Physicians. All rights reserved.

Atkins
Weight loss results
Atkins has significantly greater weight loss
than no diet
10.2 kg more at 6 months (95%CI: 8.2, 10.4)
6.4 kg more at 12 months (95% CI: 3.9, 8.9)

Johnston & colleagues. JAMA. 2014; 312:923-33. 39

Atkins
12M CVD Risk Factors
Most trials reported CVD risk factors
Blood pressure
Typically lowers SBP at least 1.5 mmHg more than
counseling
No between-group difference in DBP
Lipids
No between-group difference in LDL-c
Raises HDL-c at least 2.1 mg/dL more than counseling
Glycemia
No significant between-group difference in A1c among
patients with DM at 12 months
No between-group difference in glucose
Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 40
Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

Lose 2.7%
more than
control at 3
months

No long-term
studies

Figure Legend:
Difference in mean percentage of weight change between self-directed commercial programs (Atkins, The Biggest Loser Club, eDiets, Lose It!, and SlimFast) and
comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the percentage
of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with diabetes mellitus;
GEN = general population of overweight and obese patients; NR = not reported; P = commercial program group. *Results reported in >1 article. Results from
completers' analysis. Overall attrition at time point.

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

No significant
difference from
counseling

Figure Legend:
Difference in mean percentage of weight change between self-directed commercial programs (Atkins, The Biggest Loser Club, eDiets, Lose It!, and SlimFast) and
comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the percentage
of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with diabetes mellitus;
GEN = general population of overweight and obese patients; NR = not reported; P = commercial program group. *Results reported in >1 article. Results from
completers' analysis. Overall attrition at time point.

Copyright American College of Physicians. All rights reserved.

Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review
Ann Intern Med. 2015;162(7):501-512. doi:10.7326/M14-2238

No significant
difference from
comparison at
3 months

Figure Legend:
Difference in mean percentage of weight change between self-directed commercial programs (Atkins, The Biggest Loser Club, eDiets, Lose It!, and SlimFast) and
comparators, displayed by time point. Diamond size is standardized across trials and does not reflect the sample size analyzed. Attrition reflects the percentage
of participants unavailable for weight measurement at that time point in the trial. C = comparator group; DM = overweight or obese patients with diabetes mellitus;
GEN = general population of overweight and obese patients; NR = not reported; P = commercial program group. *Results reported in >1 article. Results from
completers' analysis. Overall attrition at time point.

Copyright American College of Physicians. All rights reserved.

Online/Mobile Programs
Short-Term CVD Risk Factors
One trial of Biggest Loser Club reported CVD
risk factors
No significant between-group differences in SBP,
DBP, LDL-c, HDL-c, or glucose at 3 months
No trials of eDiets or Lose It! reported CVD
risk factors

Mehta & colleagues. Submitted to Prev Med. 2016. Chaudhry & colleagues. Under revision at Obes Rev. 2016. 45
Head-to-Head Comparisons

Two trials have directly compared

commercial programs
No significant differences in weight change
Weight Watchers vs Atkins
Weight Watchers vs Slimfast
Atkins vs Slimfast

Dansinger & colleagues. JAMA. 2005; 293:43-53. Truby & colleagues. BMJ. 2006; 332:1309-14. 46
Summary of Evidence

Many popular commercial weight loss programs have no

evidence testing their efficacy in general populations
Short-term weight loss
Weight Watchers, Jenny Craig, Nutrisystem, HMR, OPTIFAST,
Atkins
Sustained weight loss
Many programs have no long-term trials
Weight Watchers, Jenny Craig
Atkins, Ornish, Volumetrics, Zone
Long-term CVD risk factor benefits
Limited evidence for most programs
Lower A1c with Jenny Craig among DM
Lower SBP and higher HDL-c with Atkins
THANK YOU

48