Title: Evaluation of Aintree LOSS, a community based multidisciplinary weight management service:

outcomes and predictors of engagement

Authors: Tom Steele1, Ram Prakash Narayanan1, Michaela James2, Jennifer James2, Nicky Mazey3, John P H

Wilding1

Affiliations: 1 Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, University of

Liverpool, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Liverpool, L9 7AL. 2 Aintree

Weight Management Services, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL. 3 Brownlow

Group Practice, Pembroke Place, Liverpool, L69 3GF.

Keywords: Obesity, Weight Loss, Primary Care, Socio-economic deprivation

Running Title: Community-based weight loss programme evaluation

Address for Correspondence:

John P.H. Wilding

Professor of Medicine & Honorary Consultant Physician

Obesity and Endocrinology Research

Institute of Ageing & Chronic Disease. Clinical Sciences Centre

University Hospital Aintree

Longmoor Lane

Liverpool

L9 7AL

United Kingdom

Direct Line +44(0)151 529 5899

Fax +44(0)151 529 5888

E-mail j.p.h.wilding@liverpool.ac.uk

1

Abstract

Aintree LOSS is a community-based multidisciplinary weight management programme for patients with

severe and complex obesity, focusing on a flexible and individualised service with follow up for up to 2 years.

We evaluated all 2472 patients referred to the service between October 2009-2013. Demographic data was

recorded at baseline with the Index of Multiple Deprivation (IMD) used to measure socio-economic

deprivation. Weight was recorded at each visit. Mean BMI at baseline was 45.6 (SD 6.8) and 58.9% of

patients lived in areas in the most deprived decile nationally. Of 2315 appropriate referrals, 1249 (55.1%)

attended >2 visits; mean final weight loss was 3.50±8.55kg and 24.1% achieved ≥5% weight loss. 754 patients

(33.3%) attended for over 6 months; mean final weight loss was 4.94±10kg and 34% achieved 5% weight

loss. Multivariate logistic regression analysis showed increasing age, residence in a less deprived area and

sleep apnoea to be independently associated with attendance for >6 months and there was a linear

relationship between 6-month attendance and deprivation quintile. Year-on-year analyses showed

improvement in engagement over time, coinciding with efforts to improve access to the service. This work

shows a multidisciplinary community based weight loss programme prioritising a fully flexible and

individualised approach functioning effectively in real world practice. Maintaining engagement remains a

challenge in weight loss programmes and our results suggest younger patients living in areas with greater

deprivation should be a target for efforts to improve engagement.

Introduction

The prevalence of obesity continues to increase and the United Kingdom has the highest rate in Western

Europe, making strategies to reduce the burden of obesity and its complications a healthcare priority 1, 2.

Current UK guidance recommends multicomponent interventions addressing both diet and physical activity,

taking into account individual preferences and circumstances 3. Services vary based on severity of obesity

with those with class III obesity or class II obesity with related co-morbidities suitable for specialist ‘Tier 3’

services which involve multidisciplinary input and act as a gateway to bariatric surgery for appropriate

patients.

2

The majority of published outcome data for weight loss programmes originate from research settings, which

may not reflect results encountered in real clinical practice. Furthermore, follow up periods are variable, self-

reported weights are often used and those with less severe obesity may be included, making the results less

applicable to patients with severe or complex obesity. A small number of Tier 3 programmes in the UK have

published service evaluations, however programmes offering the flexible and tailored approaches to weight

loss advocated by the National Institute for Health and Care Excellence (NICE) do not easily lend themselves

to analysis 4-8. Aintree LOSS is a Tier 3 community weight loss programme that prioritises a fully flexible and

individualised service, with a follow up period lasting up to two years.

A universal challenge to medical weight loss programmes is achieving engagement with those referred.

Understanding the demographic factors associated with poor initial and long-term engagement could help

identify specific groups to target in order to improve this outcome.

The population served by Aintree LOSS is notable for the level of socio-economic deprivation as 64.4% of the

population live in areas classified as in the most deprived quintile nationally 9. This is relevant as multiple

measures of deprivation have been shown to be associated with obesity, both in cross-sectional and

longitudinal studies 10. Reducing health inequalities related to obesity has been identified as a public health

priority, however, it is unclear whether lifestyle based interventions are accessible or adequate for patients

living in the most deprived areas 11.

Here, we describe the outcomes of Aintree LOSS, a tier 3, community-based weight loss intervention,

notable for a flexible, individualised approach. In addition, we examine the level of engagement of patients

referred, aiming to understand factors associated, at a population level, with long term engagement,

including a focus on socio-economic deprivation.

Methods

This is a retrospective analysis of all patients referred to the Aintree LOSS community weight loss

programme over a four year period, between October 2009 and October 2013.

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Intervention

Aintree LOSS is a multidisciplinary tier 3 weight management programme serving patients living in Liverpool.

Patients with a BMI >40kg/m2 or >35kg/m2 with one or more comorbidity are eligible. It is based primarily in

the community and referrals are predominantly received from primary care teams, although referrals are

also accepted from elsewhere, including secondary care and community dietetics. The team was established

in 2009 and initially consisted of general practitioners, a physician with a special interest in obesity, dieticians

and physiotherapists. It expanded to include psychologists in 2010 and occupational therapists in 2013.

Interventions, including clinics and groups, are currently delivered across six locations across Liverpool

including a hospital clinic, GP surgeries, community centres and a sports centre, with four acting as main

clinic sites and two additional group sites. The number of locations has expanded over time to increase

patient accessibility.

Rather than deliver fixed interventions over set periods of time, the programme is highly individualised, with

needs and preferences assessed in an initial meeting and reviewed frequently. Following referral the patient

is contacted by telephone and booked to their preferred site. Initial assessment is by a GP with a special

interest in obesity and includes full medical history and examination and then agreement of personalised

management plan from a pick list of dietetics, physiotherapy (hydrotherapy, individual and group advice)

and occupational therapy. Psychology is an integral part of the service, with referrals made by the GP to the

eating disorder service if meeting ICD-10 criteria or to individual and group options including cognitive

analytical and behavioural therapy (CBT/CAT) for those with abnormal eating patterns that do not meet the

ICD-10 criteria for an eating disorder. The occupational therapy service provides support for those patients

with significant disability affecting their ability to undertake activities of daily living and also provides a home

visiting service for patients who find it difficult or impossible to leave their homes. On each subsequent

medical review blood pressure, pulse and weight are recorded. Bloods (lipids, HbA1c, TSH and LFTs are taken

on initial review and followed up if necessary.

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In addition to the core multidisciplinary team led interventions there is contact with leisure services via

swimming and aquafit session referral. If appropriate, orlistat can be prescribed through the service and

liquid meal replacements can be recommended, however this is on a self-pay basis. In appropriate cases

bariatric education is provided in a group setting and there are monthly multidisciplinary team meetings to

assess suitability for bariatric surgery onward referral. Active screening is carried out for obstructive sleep

apnoea using clinical history and the Epworth screening questionnaire (ref) with direct referral to the sleep

service if appropriate. When other health issues are identified, such as type 2 diabetes, hypertension,

dyslipidaemia or thyroid disease, the patient is advised to consult their usual GP for further management.

Funding is available for 24 months attendance, however this is not necessarily used as a marker of success as

it is recognised that the desired duration of follow up will depend on the individual circumstances and

progress of the patient. Within two years of initial referral patients may leave and return to the service

without needing re-referral, including delaying engagement after initial assessment due to personal

circumstances or “readiness” and returning after dropping out for any reason.

Data Collection

Pseudonymised data was routinely collected from the electronic records of all patients referred to the

programme between October 2009 and October 2013. Follow up data was collected until November 2014 to

ensure follow up results for all patients for a minimum of 12 months. Sex, age and postcode were available

for all referrals. Anthropometric data and co-morbidities were recorded for those who attended at least

once, with weight measured at each subsequent face to face visit. Those who attended the initial visit but

were not eligible to take part were excluded from further analyses.

Given the flexible, open ended nature of the programme the primary outcome measures were final weight

change and the proportion of patients with any, 5kg and 5% weight loss at their final visit versus baseline. To

assist comparisons with other programmes, these results are also reported at 3, 6 and 12 months, both for

completers and all participants using baseline observation carried forward (BOCF) and last observation

carried forward (LOCF) analyses. Attrition at each stage of the process, from referral onwards, was assessed.

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A basic level of engagement was taken to be attendance at the initial assessment and at least two further

sessions, whilst six months was taken as the threshold for long-term engagement.

Measures of socio-economic deprivation

The index of multiple deprivation (IMD) was used a measure of socio-economic deprivation, based on

patient postcode. This is the official measure of relative deprivation in England; ranking 32844 small areas of

similar population size (average of 1500) according to deprivation, calculated across seven weighted

domains; income, employment, education, health, crime, barriers to housing and services and living

environment 9. Both the national decile rank and local quintile was calculated for each participant.

Statistical analysis

All statistical analyses were performed using SPSS version 20 for Windows (IBM Corp, USA). Data was

assessed for normality of distribution and statistical tests used as appropriate. For determining predictors of

long term engagement, attendance of greater than six months was used as a binary outcome measure.

Variables with p<0.2 on univariate analysis were entered into a multivariate binary logistic regression model

for predictors of engagement. A p-value of < 0.05 was considered statistically significant.

Ethical approval

This was an analysis of non-identifiable data extracted for the purpose of evaluating a routine UK National

Health Service (NHS) programme and therefore did not require ethical approval. Approval for the evaluation

was granted by the managing hospital trust (Aintree University Hospital NHS Foundation Trust).

Results

2472 referrals were made over the study period, with sufficient data for inclusion available for 2457. Mean

age was 48.6 (SD 13.8) and 71.6% were female. 12.6% of patients referred returned to the service on more

than one occasion (1.1% on 3 occasions), in these cases data was analysed from first engagement with the

service (>2 attendances). IMD could be accessed for 2438 referrals. 58.9% of patients lived in areas in the

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most deprived decile nationally and 91.3% lived in areas in the most deprived 50%. Figure 1 is a flow chart

showing attrition over time of referrals to the service. 1926 (78.4%) of patients referred attended on at least

one occasion and had valid weights and information on co-morbidities available for analysis. Mean baseline

weight was 127.1kg (SD 23.3) and BMI 45.6 (SD 6.8). Table 1 summarises baseline characteristics of those

that attended at least one appointment. Those who were referred but never attended were younger

(46±14.7 vs 49.2±13.5; p<0.001) and tended to be from more deprived areas (23.6% vs 19.9% from most

deprived quintile; p=0.06) than those that attended at least once.

Mean weight change of all patients who attended on more than two occasions was -3.50±8.55kg. Mean

weight change of those attending for 6 months or more was -4.94±10.0kg. Overall 66.1% lost weight, rising

to 70.3% in those who attended for >6 months. 24.1% lost more than 5% of their initial body weight overall,

this was 34% in those attending for >6 months. 9.5% lost more than 10% of their initial body weight overall;

14.7% in those attending for >6 months. The follow up period was very variable, reflecting the flexible nature

of the programme, Table 2 shows results stratified by length of time in follow up. In order to aid comparison

with other weight loss programmes we also calculated outcomes at 3, 6 and 12 months, displayed in Table 3.

117 patients (4.8% of all referrals; 9.4% of “engagers”; 15.5% of those attending for >6 months) were

referred for bariatric surgery.

Table 4 examines associations between a number of variables and outcome (engagement >6 months and 5%

weight loss). Those who attended for more than 6 months were significantly older (51.7±12.9 vs 47.8±13.7;

p<0.001) and also more likely to have a number of co-morbidities including diabetes, sleep apnoea,

hypertension and joint pain. Those who failed to complete 6 months tended to be more likely to be from the

most deprived quintile of the population but this was not statistically significant (21% vs 17.9%; p=0.1).

Amongst those who completed at least 6 months in the programme, no factor was identified that was

significantly associated with >5% weight loss. Multivariate logistic regression showed increasing age (OR

1.017; 95% CI 1.008-1.026; p<0.001), residence in area in less deprived quintile (OR 1.082; 95% CI 1.012-

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1.157; p=0.02) and presence of sleep apnoea (OR 1.357; 95% CI 1.077-1.710; p=0.001) to be associated with

attendance for >6 months.

In order to better understand the role of deprivation, comparisons were made between demographics,

prevalence of co-morbidity and outcome according to IMD deprivation quintile (Table 5). This showed a

difference in age and BMI, with those resident in the least deprived areas significantly older and with a lower

BMI, but no difference in prevalence of diabetes or co-morbidity. There was a linear relationship between

the proportion of patients attending for over 6 months and deprivation quintile with 36.3% of those living in

the most deprived quintile of areas completed 6 months follow up, compared to 46.7% in the least deprived.

In those that completed 6 months there was no significant difference in weight loss according to IMD

quintile.

Table 6 shows year on year comparisons through the study period. As shown the number of sites has

increased, and additional services such as group sessions and evening appointments introduced over time.

The table shows no change in demographics each year, but does show a linear increase in engagement for

over 6 months each year, more pronounced in the most deprived quintile of the population.

Discussion

This study describes real world data from a Tier 3 community based weight loss programme over a four year

period in a UK region with significant socioeconomic deprivation. The key factor for Aintree LOSS is its

individualised, flexible approach, which is tailored to each patient, though this means interpretation of data

is challenging. Patients engaged with varying degrees of intensity according to their current circumstances.

The majority of patients lost weight and the best results were seen in those attending for longer periods of

time. Although the weight loss observed is modest, the population is an unselected, real world sample,

including those with complex health problems. In addition, Aintree LOSS patients are afforded individualised

access to multidisciplinary professionals, including psychology and occupational therapy, other medical

specialties and bariatric surgery, meaning benefits can go far beyond weight loss alone.

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A limited number of Tier 3 services have published data for comparison. Glasgow and Clyde Weight

Management programme published a real world service evaluation in 2014 for a large cohort with similar

demographics to Aintree LOSS 4. In contrast with Aintree LOSS, this programme had defined structured

stages, however BOCF, LOCF and data for completers were reported, although caution should be applied in

using these for direct comparison as further changes in weight, especially regain are likely after leaving the

service. The 5% weight loss using LOCF at the end of the third phase of the Glasgow programme was similar

to the 12 month results reported here, although the follow up period was longer. At 12 months their 5%

weight loss rates for completers was notably higher, but BOCF lower, which is likely due to the fact a higher

proportion of Aintree LOSS users were counted as reaching this point as there was no minimum number of

sessions to be achieved, in contrast to ≥6 sessions in the Glasgow paper. A further study, based in Norfolk,

reported BOCF and completion data with very favourable results, including 5% weight loss of 44.3% using

BOCF at 12 months. However, it is notable that patients were specifically recruited for this service evaluation

and were asked to sign a contract to attend regularly. Attrition rates were very low in keeping with this and

the overall sample was small in comparison with the Aintree LOSS cohort. Results from other NHS service

evaluations appear similar to here, although the outcomes reported and varying follow up periods make

comparison difficult 5, 6, 8.

The issue of poor initial engagement and high subsequent attrition is well established in medical weight loss

programmes 12, 13. The follow up at Aintree LOSS, although funded for 2 years is open to patient preference,

therefore no particular follow up period is designated a success. However, higher attendance is known to be

associated with greater weight loss14. Excluding inappropriate referrals, 54% of those referred attended on 3

or more occasions, suggestive of some meaningful engagement, and 33% for over 6 months. Despite its

importance, levels of engagement from the point of referral is not universally reported in service

evaluations, whilst in trial settings patients are recruited and resources are channelled into ensuring follow

up. The results here compare favourably to those reported in other service evaluations. A programme in

Halifax showed 27% of eligible referrals still enrolled at 24 weeks, and in Glasgow 33% of eligible referrals

enrolled on their programme and 11% of those completed the full programme 4, 6. The flexibility of Aintree

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LOSS may have a positive impact on these results, and although some long-term attendees may do so at a

relatively low intensity, they will benefit from the services on offer that they may have missed out on if

higher intensity engagement was demanded.

Given the diversity of weight loss programmes, factors associated with attrition are poorly defined. A

systematic review suggested that demographic, psychological, cognitive and practical issues are all relevant.

The strongest association we found with poor engagement was younger age. This association is well

established and has been noted in similar populations 7, 15. This could be related to greater health awareness

in older patients and we also identified higher levels of diabetes, sleep apnoea and joint pain in engagers.

On multivariate regression analysis, along with age, living in a less deprived area was associated with

attendance for ≥6 months. This is especially relevant given the association between deprivation and obesity

and the high levels of deprivation in the Aintree LOSS population. Different measures of deprivation used

worldwide limits the availability of data for comparison, however several studies have noted a higher level of

education to be predictive of retention in weight loss programmes 16-19. A higher dropout amongst those

living in areas with the highest levels of socio-economic deprivation was also described in the first phase of

the Glasgow Tier 3 service evaluation 20.

There appears to be a linear relationship between higher levels of deprivation and lower levels of

engagement in our population, but no difference in weight loss success. This suggests improvements in

engagement should lead to better outcome overall. Young patients in particular in these areas merit

attention as differences in engagement meant that, of the total initially referred, the proportion of those

under 40 years from the most deprived decile nationally losing 5% body weight was less than half of those

over 50 years from less deprived areas (6.8% vs 17.3%).

Since the establishment of Aintree LOSS there has been a policy of continuous improvement with a focus on

improving rates of attendance, including expanding the number of sites used to reduce travel time, using

text message reminders for appointments and offering more flexible appointment times. Comparisons year

on year did show improvement of engagement. Causality of this cannot be ascribed for certain, however,

10

increases coincided with the improvements outlined above; such factors have previously been suggested to

be associated with retention in weight loss programmes 13, 15. Although weight loss amongst engagers did not

change, the proportion of the overall population referred who lost significant weight increased as a result of

the increased engagement. These findings give encouragement to on-going efforts to expand the service and

make it more accessible. In particular, an ‘opt in’ system is currently being piloted in one health centre,

giving patients the opportunity to opt in and quickly access appointments when they feel ready. Preliminary

data is encouraging and this approach is consistent with latest NICE guidance 3.

This evaluation has a number of limitations. It is deliberately an analysis of real world data from a service

that is highly individualised, but this does make interpretation challenging due to the heterogeneity of

intervention. In addition there is no control group for comparison. The flexible follow up period makes

comparisons with other weight loss programmes difficult. We have attempted to facilitate this by reporting

outcomes at specified time points and using BOCF and LOCF, in keeping with other studies, however LOCF in

particular has limitations in this context4,7. A significant proportion of patients are likely to regain weight

after stopping attending for any reason, meaning LOCF at specific time points should be interpreted with

caution. Given the data available, we were unable to look at important outcome measures such as blood

pressure, glycaemic control physical functioning and psychological measures, while over the study period

data on quality of life, physical activity and dietary change were not consistently enough recorded to be

included in analyses. Finally, when looking at engagement with the program, it was impossible to analyse all

the possible predictors so important associations may not have been picked up and information on why

participants stopped attending over time was not available.

Conclusion

This work shows a fully flexible and individualised multidisciplinary, Tier 3 community based weight loss

programme for severe and complex obesity functioning effectively in real world clinical practice. In this

population with high levels of social deprivation, encouraging engagement is a challenge. The service

continues to evolve with efforts to improve access coinciding with year-on-year improvements in

11

engagement seen during the study period. Our results suggest younger participants and those in the most

deprived areas could be specific targets for further attempts to increase engagement.

Conflicts of interest

TS, RPN, MJ, JJ and NM have no conflicts of interest to declare. JW reports grant income, lecture fees and

institutional consultancy fees from Novo Nordisk outside of the submitted work and institutional consultancy

fees from Orexigen outside of the submitted work.

Acknowledgements and author contributions

JW, MJ, JJ and NM are the lead clinical team members for Aintree LOSS and contributed the data. JW, TS and

RPN conceived and planned the evaluation. TS and RPN processed the data and TS performed the analyses.

All authors gave advice on data analysis and presentation of results. All authors contributed to the writing of

the paper and approved the final submitted version. We would like to acknowledge the work of the team

members of Aintree LOSS, the Liverpool City Council who commission the service and Aintree University

Hospital NHS Foundation Trust who supported the service evaluation. As this was a service evaluation and all

authors’ full-time trust or university staff members, no funding was required.

References

1 Scantlebury R, Moody A. Adult obesity and overweight. Health Survey for England 2015; 1-17.2 Yumuk V, Tsigos C, Fried M et al. European Guidelines for Obesity Management in Adults. Obesity Facts. 2015; 8: 402-24.3 National Institute for Health and Care Excellence. Obesity: identificaton, assessment and management. 2014.4 Logue J, Allardice G, Gillies M, Forde L, Morrison DS. Outcomes of a specialist weight management programme in the UK National Health Service: prospective study of 1838 patients. BMJ Open. 2014; 4: e003747.5 Brown A, Gouldstone A, Fox E et al. Description and preliminary results from a structured specialist behavioural weight management group intervention: Specialist Lifestyle Management (SLiM) programme. BMJ Open. 2015; 5: e007217.6 Wallace D, Myles P, Holt R, Van-Tam JN. Evaluation of the "Live Life Better Service", a community-based weight management service for morbidly obese patients. Journal of Public Health. 2016; 38: e138-e49.7 Jennings A, Hughes CA, Kumaravel B et al. Evaluation of a multidisciplinary Tier 3 weight management service for adults with morbid obesity, or obesity and comorbidities, based in primary care. Clinical Obesity. 2014; 4: 254-66.

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8 Nield L, Kelly S. Outcomes of a community-based weight management programme for morbidly obese populations. Journal of Human Nutrition and Dietetics. 2016; 29: 669-76.9 Department for Communities and Local Government. English Indices of Deprivation 2010. In: Department for Communities and Local Government (ed.): 2011.10 El-Sayed AM, Scarborough P, Galea S. Unevenly distributed: a systematic review of he health literature about socioeconomic inequalities in adult obesity in the United Kingdom. BMC Public Health. 2012; 12.11 Hillier-Brown FC, Bambra CL, Cairns J-M, Kasim A, Moore HJ, Summerbell CD. A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults. International Journal of Obesity. 2014; 38: 1483-90.12 Brook E, Cohen L, Hakendorf P, Wittert G, Thompson C. Predictors of attendance at an obesity clinic and subsequent weight change. BMC Health Services Research. 2014; 14.13 Moroshko I, Brennan L, O'Brien P. Predictors of dropout in weight loss interventions: a systematic review of the literature. Obesity Reviews. 2011; 12: 912-34.14 Stubbs RJ, Pallister C, Whybrow S, Avery A, Lavin J. Weight Outcomes Audit for 34271 Adults Referred to a Primary Care/Commercial Weight Management Partnership Scheme. Obesity Facts. 2011; 4: 113-20.15 Spring B, Sohn M-W, Locatelli SM, Hadi S, Kahwati L, Weaver FM. Individual, facility, and program factors affecting retention in a national weight management program. BMC Public Health. 2014; 14: 363.16 Hadziabdic M, Mucalo I, Hrabec P, Matic T, Rahelic D, Bozikov V. Factors predictive of drop-out and weight loss success in weight management of obese patients. Journal of Human Nutrition and Dietetics. 2015; 28: 24-32.17 Fabricatore AN, Wadden TA, Moore RH, Butryn ML, Heymsfield SB, Nguyen AM. Predictors of Attrition and Weight Loss Success: Results from a Randomized Controlled Trial. Behaviour Research and Therapy. 2009; 47: 685-91.18 Bradshaw AJ, Horwath CC, Katzer L, Gray A. Non-dieting group interventions for overweight and obese women: what predicts non-completion and does completion improve outcomes? Public Health Nutrition. 2010; 13: 1622-8.19 Elfhag K, Rossner S. Initial weight loss is the best predictor for success in obesity treatment and sociodemographic liabilities increase risk for drop-out. Patient Education and Counseling. 2010; 79: 361-6.20 Morrison D, Boyle S, Morrison C, Allerdice G, Greenlaw N, Forde L. Evaluation of the first phase of a specialist weight management programme in the UK National Health Service: prospective cohort study. Public Health Nutrition. 2011; 15: 28-38.

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Characteristic Number %Female sex 1368 70.9Age: <30 30-39 40-49 50-59 60-69 ≥70

181295456541353103

9.415.323.628.018.35.3

IMD national decile: 1st (most deprived) 2nd 3rd 4th

5th

6th

7th

8th

9th

10th (least deprived)

11123231221047489711462

5816.86.45.43.94.63.70.70.30.1

BMI: <35 35-39.9 40-44.9 45-49.9 ≥50

32350622473435

1.718.332.524.722.8

Diabetes 501 26Sleep Apnoea 418 21.7Depression 920 47.7Hypertension 768 39.8Hyperlipidaemia 625 32.4Myocardial Infarction 101 5.2Ischaemic heart disease 132 6.8Stroke 63 3.3Joint pain 912 47.3

Table 1: Baseline characteristics of those attending initial session with Aintree LOSS (n=1929). IMD: Index of Multiple Deprivation.

Follow up period

Number Mean WL (kg±SD)

Some WL n(%)

>5kg WL n(%) >5% WL n(%)

<6 months 493 -1.29±4.88 296 (59.9%) 84 (17%) 44 (8.9%)6-12 months 337 -3.39±6.96 228 (67.7%) 110 (32.6%) 88 (26.1%)12-18 months 185 -4.27±8.94 137 (74.1%) 77 (41.6%) 66 (35.7%)>18 months 232 -7.72±13.4 165 (71.1%) 114 (49.1%) 102 (44%)

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Table 2: Outcomes (derived from final weight) depending on length of follow up amongst engagers (>2 sessions). SD: Standard Deviation; WL: Weight Loss.

N Mean weight change (95% CI)

Some WL n(%) >5kg WL n(%) >5% WL n(%)

All* 1249 -3.50 (±8.55) 828 (66.3%) 386 (30.9) 301 (24.1)3 months Completers All BOCF All LOCF

104112491249

-1.62 (±4.19)-1.35 (±3.87)- 1.52 (±4.04)

663 (63.7%)663 (53.1%)787 (63.0%)

169 (16.3%)169 (8.2%)195 (15.6%)

103 (9.9%)103 (8.2%)112 (9%)

6 months Completers All BOCF All LOCF

75512491249

-3.1 (±6.37) -1.87 (±5.18)-2.49 (±6.68)

522 (69.1%)522 (41.8%)821 (65.7%)

235 (31.1%)235 (18.8%)322 (25.8%)

189 (25%)189 (15.1%)235 (18.8%)

12 months Completers All BOCF All LOCF

41012491249

-3.95 (±8.59)-1.29 (±5.25)-2.85 (±7.62)

274 (66.8%)274 (21.9%)806 (64.5%)

170 (41.5%)170 (13.6%)368 (29.5%)

142 (34.6%)142 (11.4%)278 (22.3%)

Table 3: Outcomes at specified time from first attendance. * All those who engaged with service (>2 sessions) included. CI: Confidence Interval; WL: Weight Loss; BOCF: Baseline Observation Carried Forward; LOCF: Last Observation Carried Forward.

Characteristic <6 months attendance (n=1127)

>6 months attendance (n=754)

P value <5% WL (>6 months)

5% WL (>6 months)

P value

Age 47.8±13.7 51.7±12.9 <0.001 51.4±13.0 52.1±12.7 0.45Female Sex 790 (70.1%) 536 (71.1%) 0.65 358 (71.9%) 178 (69.5%) 0.5Most deprived quintile of population

235 (21.0%) 134 (17.9%) 0.1 92 (18.6%) 42 (16.4%) 0.32

Most deprived decile nationally

666 (59.1%) 416 (55.2%) 0.09 282 (56.6%) 134 (52.3%) 0.26

BMI 45.7±6.67 46.1±6.85 0.19 45.7±6.79 46.7±6.95 0.074Diabetes 267 (23.7%) 231 (30.6%) 0.001 152 (30.5%) 79 (30.9%) 0.8Sleep Apnoea 212 (18.8%) 206 (27.3%) <0.001 133 (26.7%) 73 (28.5%) 0.6Depression 532 (47.2%) 368 (48.8%) 0.5 245 (49.2%) 123 (48%) 0.77Hypertension 431 (38.2%) 334 (44.3%) 0.009 221 (44.4%) 113 (44.1%) 0.95Hyperlipidaemia 348 (30.9%) 276 (36.6%) 0.01 179 (35.9%) 97 (37.9%) 0.6Ischaemic heart disease 75 (6.7%) 56 (7.4%) 0.52 36 (7.2%) 20 (7.8%) 0.77Joint pain 495 (43.9%) 403 (53.4%) <0.001 269 (54%) 134 (52.3%) 0.66

Table 4: Comparison of patient characteristics based on 6 months attendance (of those who were eligible and attended an initial session) and 5% weight loss (in those attending >6 months). WL: Weight Loss.

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Variable 1st quintile (most deprived)

2nd quintile 3rd quintile 4th quintile 5th quintile (least deprived)

P value

N 504 485 484 479 486Age^Female Sex^BMI§

Diabetes§

≥1 co-morbidity§

48.4 (47.1-49.8)266 (72.1)45.4 (44.7-46.1)93 (24.4%)226 (59.3%)

48.7 (47.4-50.1)275 (72)46.3 (45.6-47.1)112 (28.9%)248 (63.9%)

48.1 (46.7-49.5)250 (69.1)46.1 (45.3-46.8)93 (25.4%)233 (60.8%)

48.9 (47.6-50.2)263 (69.6)45.4 (44.8-46.0)95 (25%)231 (60.8%)

52.2 (50.9-53.5)264 (69.7)44.8 (44.2-45.5)105 (26.8%)248 (63.3%)

<0.0010.015 0.0150.370.18

Never attended^ 123 (24.4%) 92 (19%) 115 (23.8%) 96 (20%) 95 (19.5%) 0.14Engaged (>2 sessions)^

232 (46%) 243 (50.1%) 248 (51.2%) 247 (51.6%) 272 (56.0%) 0.003

Follow up*: >6 months >12 months

134 (36.3%)81 (22%)

149 (39%)80 (20.9%)

144 (39.8%)79 (21.8%)

146 (38.6%)74 (19.6%)

177 (46.7%)102 (26.9%)

0.010.15

Outcome$: Mean weight change >5% weight loss

-3.83 (-5.36 to -2.3)42 (31.3%)

-4.45 (-6.15 to -2.76)46 (30.9%)

-5.39 (-7.1 to -3.69)48 (33.3%)

-5.86 (-7.36 to -4.37)58 (39.7%)

-5.15 (6.75 to -3.54)62 (35%)

0.46

0.2

Table 5: Comparison of patient characteristics, engagement and outcome across deprivation quintile. ^ All patients. § All who attended one session. * All who attended one session and eligible to proceed n=1870 (11 missing socio-economic data). $ All who attended for >6 months (n=750, 4 with missing deprivation data). P values calculated by chi-square test linear-by-linear association.

Variable 2009-10 2010-11 2011-12 2012-13 P valueReferrals (excluding DNA and not eligible)

493 521 454 404

Number of sites 4 5 6 6Age

Sex

BMI

Diabetes

49.3 (48.2-50.4)

369 (72.5%)

45.8 (45.2-46.4)

143 (28.1%)

48.8 (47.6-49.9)

384 (71.4%)

45.6 (45.1-46.2)

149 (27.7%)

48.8 (47.5-50.0)

313 (67.5%)

45.6 (45.0-46.3)

105 (22.6%)

48.8 (47.5-50.2)

299 (72%)

45.4 (44.7-46.0)

106 (25.5%)

0.87

0.5

0.83

0.14

Engagement: > 6 months (all eligible) >6 months (most deprived quintile)

161 (32.7%)

23 (23.5%)

202 (38.8%)

42 (40.8%)

205 (45.2%)

35 (40.7%)

186 (46%)

34 (42%)

<0.001

0.013

Outcome:All eligible: Mean WC Some WL 5% WL>6 months: Mean WC Some WL 5% WL

-3.27±9.84191 (38.7%)69 (14%)

-5.55±12.4106 (65.8%)57 (35.4%)

-3.08±7.60220 (42.2%)80 (15.4%)

-4.00±9.10137 (67.8%)67 (33.2%)

-4.00±8.81210 (46.3%)78 (17.2%)

-5.31±9.67150 (73.2%)68 (33.2%)

3.68±7.76205 (50.7%)73 (18.1%)

-5.01±8.99137 (73.7%)64 (34.4%)

0.530.0020.07

0.450.270.96

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Table 6: Year on year comparison of patient characteristics, engagement and weight loss in Aintree LOSS. Periods described are October to October due to when LOSS started. WC: Weight Change; WL Weight LOSS.

Figure 1: Flow chart showing attrition of referrals to Aintree LOSS.

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