This site is intended for health professionals only

At the heart of general practice since 1960

pul jul aug2020 cover 80x101px
Read the latest issue online

Independents' Day

Study: GPs 'should support' patients on meal-replacement weight-loss programmes

GPs can confidently support patients on total diet replacement programmes as they may be a safe and effective way for obese patients to lose weight, a study has suggested.

Obese patients who went on a program of total diet replacement with behavioural support lost more weight than patients who received usual care, the study found.

The study was carried out by researchers at the University of Oxford and looked at just under 300 patients who sought help from their GP to lose weight.

Around half of the patients were assigned to receive standard care, including dietary advice and behavioural support from their practice nurse, and half were assigned to a program of total diet replacement (TDR).

The TDR intervention included using calorie-controlled meal replacement products for eight weeks before scaling down to using one product a day, in addition to behavioural support from a counsellor up until 24 weeks. The products and counsellors were supplied by Cambridge Weight Plan UK, who also part-funded the study.

The researchers found that at 12 months after starting the interventions, patients in the TDR group had lost, on average, around 11kg, compared to 3kg in the usual care group. They also found that the TDR group had greater reductions in HbA1C levels and diastolic blood pressure compared to the usual care group.

They noted that GPs tend to be ‘wary’ about supporting people who choose total diet replacement programmes, but said that their study should provide reassurance.

They said in the paper: ‘Current clinical guidelines recommend that this type of diet is reserved for people in whom short term weight loss is a priority—for example, before bariatric or knee replacement surgery, and they are not recommended as routine weight loss interventions. This presumably reflects concerns that weight loss is short lived.

‘This trial shows that TDR leads to greater weight loss at one year than an intervention based on usual food.’

Dr Rachel Pryke, GP and RCGP clinical advisor on obesity and nutrition, said that the study could give GPs more confidence if patients choose to follow TDR programmes, but queried how feasible it would be to incorporate TDR in to wider obesity strategies.

She said: ‘Mass rollout is not yet in any way realistic because the programme clearly needs long-term behavioural support alongside the TDR – which is not typically available by GPs. The staff giving that support need training, time and a structured clinic environment. So how this could be provided is the next vital question. I hope the study will create more noise about funding of obesity services in general.

‘If the behavioural support continued to be available then perhaps this would be a real way forward. However in light of current financial constraints, I think the true potential of this study may be limited by the ability of the NHS to fund the necessary services for it to be effectively delivered long-term.’

BMJ 2018; available online 27th September

Readers' comments (24)

  • David Banner

    “Meal replacement products”? Anyone remember Slimfast et al? Brilliant success that was back in the day. And now (presumably) we’ll be expected to prescribe this rubbish? Look, it either won’t work, or any temporary effect will reverse on their next Benidorm holiday. We should have nothing to do with this short term trendy nonsense. If patients want to fritter away their own cash on such items then fine, but GPs shouldn’t touch it with a barge pole.

    Unsuitable or offensive? Report this comment

  • Hawkeye

    All that spare time we have in Primary care.
    Ivory Towers again.

    Unsuitable or offensive? Report this comment

  • DO these GP actually work and see patients? Haven't these so called ivory towers GPs heard of "PRIORITIES". NHS funding is in dire state. peoples operations are being postponed for months. Waiting times are as long as they can be. CCG have started rationing and these ....heads wants us to support meal replacement weight programme on NHS. I think they need to go and see psychiatrist.

    Unsuitable or offensive? Report this comment

  • Ivory tower socialists/leftists are being entirely logical. They just want to buy patient's votes by taking their responsibility and fking everyone else over. Makes sense really if you know what the left/socialists want.

    Unsuitable or offensive? Report this comment

  • @the four lunatics who have already posted above be.

    What are you talking about? If ANY anti diabetic drug had as good of an outcome as meal replacements it would be mandatory to prescribe and use it.

    If ANY drug had as much benefit with is few side effects then it would be touted as a wonder cure and there would be plenty of funding for it.

    This is exactly the type of thing that should be supported in primary care and I'm surprised at my colleagues attitudes / responses.

    Unsuitable or offensive? Report this comment

  • The study authors have made a gross error in generalising inappropriately.
    Their study actually showed that patients should be supported by Cambridge Counsellors and Practice Nurses, but there is NO evidence from this study for ANY benefit from support from GPs.
    This is poor quality science.

    Unsuitable or offensive? Report this comment

  • @The Man' Daddy.- Before you start calling names to your colleagues. 1) The above study is not limited to diabetic it is for general obese patients.
    2) Diabetic are already supported well by help of dietitian support / specialized diabetic nurses. If they want to support patient to loose weight by giving them gold shakes let it come from special funding. We have no problem with that
    3) My problem is making genralisation . Every obese patient will ask for this replacement diet, then what are you going to do? Most of these replacement diet shakes cost around 100 £/ person / month. Considering 25 % of population is obese in community are we going to fund this at the cost of cutting down our heart & knee operations?

    Unsuitable or offensive? Report this comment

  • Clearly TheManNANNY doesn't care about the ever-growing health budget or overworked GPs. All evidence also shows that if you eat little enough you would lose weight. Therefore, 'failure to lose weight' is a lack of effort/self-inflicted. How about letting these patients take more responsibility instead of NANNYING them every step of the way. You might be happy for your tax to be frittered away on this, but I'm not.

    Unsuitable or offensive? Report this comment

  • @pradeep

    Diabetic nurses can't take clinical responsibility for novel approaches, that's why doctors exist and everything isn't nurse led.

    My point is that we should be fighting for resources that can help the patient.

    We are under resourced at the moment but we should be fighting for more.

    The cost you point out for diet replacement meals is negligible compared to the long term costs of diabetes/obesity and complications such as IHD and stroke.

    In other words you're being short sighted and not thinking.

    @christopher ho

    The health budget will get even worse if obesity and all of its associated health conditions aren't tackled. So your argument is already a non starter.

    Also, you as a GP are already helping patients who have made poor lifestyle choices by giving them antihypertensives, providing antidiabetic agents, referring to dieticians, referring for gastric operations etc.

    So WHY have you drawn the line at providing dietary supplements etc. Why have you decided that this is precisely where we should draw the line in providing care?

    We're in the game of providing healthcare. If you think there's a socialist agenda or something by providing proven care to our patients then perhaps you should reconsider your profession.

    Unsuitable or offensive? Report this comment

  • @ManNanny, its you who are being short sighted. Nannying the patient is not 'helping' them. Oh I draw the line way further upstream, therefore before I give anyone antihypertensives, antidiabetics, etc I rationalise to them lifestyle advice, personal responsibility, the state of our budget both healthcare and welfare, before I TAKE responsibility away from them. There is a clear socialist agenda when we're continuing to increase our healthcare budget despite the Treasure being bankrupt. Oh I believe I provide BETTER healthcare by enabling people to take more responsibility for their own health, and not rely on the state. Maybe you should reconsider what you are actually doing by furthering the socialist agenda at the cost to everyone else.

    Unsuitable or offensive? Report this comment

  • So one group had specialised counselling, the other didn't. Therefore the study is null and void as this could have been the intervention leading to weight loss.

    Unsuitable or offensive? Report this comment

  • Absolute no suprise to read that the RCGP supports dumping more unfunded work on GPs.

    Why does anyone remain a member and fund these Quislings?

    Unsuitable or offensive? Report this comment

  • I do think there is a role for primary care to support people to lose weight if they want to, to help reduce cardiovascular disease, reduce diabetic prescribing, and improve wellbeing. If primary care was funded for this, costs could be recouped in reduction in need for diabetic meds/antihypetensives, maybe more.

    However I'm not convinced that this is the way forward.

    Firstly, the research was funded by the Cambridge Weight Plan.

    Secondly, it is not surprising that those on a very low calorie diet, enabled by the supportive counsellors, lost more weight. The question is - can this be maintained longterm? The trial only covers 12 months, and the rate of weight gain in the meal replacement group after 6 months is more rapid than for the other. We know that very low calorie diets lead to a reduction in metabolic rate, which is why so many people regain all the weight lost and then some with these diets. Maybe we should be looking more at supporting patients with real nourishing food, using techniques such as intermittent fasting and restricted time feeding, which are more likely to be sustainable in the longterm.

    Unsuitable or offensive? Report this comment

  • @northwestdoc
    @sandra teare

    It's rather unusual why this study is making headlines now. I first came across the findings last winter in the bmj.

    Full findings here:

    It is a preliminary study, however as I mentioned before if this was an actual drug with the main side effect being a tad bit of constipation then it would already have millions pounds worth of funding and on going trials.

    Ps, no I'm not in any way affiliated with this study. I'm just a regular coal face GP partner.

    Unsuitable or offensive? Report this comment

  • David Banner

    @Man’s Daddy

    Fair points, but it’s not fair to label us “lunatics”. We all know that significant weight loss will dramatically help our diabetic patients, this is hardly news, and there have been countless studies proving this.
    We’ve all seen bariatric surgery diabetics virtually cured, and TV programmes featuring closely monitored punters swigging shakes with remarkable HbA1c reductions. All very impressive.
    But in the real world this never works.
    We’ve all seen scheme after scheme of weight loss initiatives crash and burn over decades, and the obesity crisis worsen year after year.
    So now we might be expected to start prescribing some souped up Slim-fast at enormous cost, and presumably taken up with great enthusiasm by potentially millions of obese diabetics.
    With no TV cameras around do we seriously think these unfortunate patients will stick to their shakes and forfeit food?
    Look at the ruinous cost of prescribing Ensure et al to the often have you had to heave the door open blocked by dozens of unopened out of date cartons of the stuff?
    But as there will be no prescription charge for these products the demand is likely to be enormous, driven by media hype.
    Surely a leaflet with low calorie guidelines for the few genuinely dedicated patients will suffice, rather than piddling away millions on expensive trendy shakes.
    Modest metformin may only have a small impact, but it’s cheap and cheerful (once you get used to the diarrhoea), and crucially most patients will continue on it for years....long after they ditched the Slim-fast for KFC.

    Unsuitable or offensive? Report this comment

  • I am just glad I left three years ago after 23yrs of full time clinical practice. Year on year there seemed to be less and less patient responsibility. 'I can't stop smoking - what are YOU going to do about it Doc?' 'I can't stop eating - what are YOU going to do about it Doc?' 'I take too many street drugs - what are YOU going to do about it Doc?' 'I don't like getting old - what are YOU going to do about it Doc?'.
    I now have a non-medical company selling on the internet via Amazon and our own sites and I am rather embarrassed to say it is more enjoyable and profitable. The NHS is doomed, before long GPs will be asked to check patient's bottoms after they have defecated to check they are clean enough and prevent rashes. Too mad for me.

    Unsuitable or offensive? Report this comment

  • The Mans Daddy- I can see how it works. Its a good psychological way of achieving portion control- i.e. its done for you just stick to it, you don't have to make up your own full weeks calorie controlled meals. A guy did very similar in the US eating just subway. And would I advocate patients doing it- yes, of course, give it a try. I just don't think the study is that good. The reason we use so many drugs is because they are very easy to placebo hence easier to prove they work- even if the benefit is modest and side effects severe

    Unsuitable or offensive? Report this comment

  • We will be doing ' The Cambridge Diet ' out of business. They are set up to provide psychological and motivational support.

    In the past I have directed patients to them, in fact I have successfully used them myself. It took a good few years for the weight to come back, but I had learnt a lot about the ability of my body to experience hunger and not succumb.

    I now successfully maintain weight loss with a low carb diet and exercise. These are approaches I prefer for patients but many are so wedded to their cereal for breakfast and sandwiches, that it does not work. It is a rare few that succeed. I tend to be less evangelical now, as I know it is futile, and I do not have time to waste.

    Unsuitable or offensive? Report this comment

  • i tell my patients to lose weight or they will develop all the complications, diabetes etc and if they do i reserve the right to say i told you so. I tell them I don't put the food in their mouth, its their choice. its amazing how many go and lose weight. Give patients back the responsibility for their own health choices. obesity is not a medical condition - its a behavioral one. So talk to them about it. stop enabling them with a get out clause of a medical treatment rather than confront their own behavior.

    Unsuitable or offensive? Report this comment

  • Keep up the straw man arguments people!

    Instead of dealing with points such as;

    1) why is a diet which is safer and more effective than drugs available the line we should draw in helping patients.

    2) Why shouldn't the NHS help people who will create a greater burden on society by not helping them (again, in which case why do ANY preventative treatments).

    Really makes us GPs look great as a profession when we don't learn and move forward with new data which should be looked into further...

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say