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Open access Original research
Weight loss, hypertension and mental BMJNPH: first published as 10.1136/bmjnph-2020-000219 on 15 February 2021. Downloaded from
well- being improvements during
COVID-19 with a multicomponent
health promotion programme on Zoom:
a service evaluation in primary care
1,2 1 3
Louise Walker, Natalie Smith, Christine Delon
To cite: Walker L, Smith N, ABSTRACT (T2D), hypertension and cardiovascular
Delon C. Weight loss, Background Obesity is a risk factor for complications 1
hypertension and mental disease are an ongoing problem globally.
well- being improvements from SARS- CoV-2 infection, increasing the need for In England, 63% of adults are overweight or
effective weight management measures in primary care. 2
during COVID-19 with a obese, which is a risk factor for COVID-19
multicomponent health However, in the UK, COVID-19 restrictions have hampered complications.3 4 Furthermore, UK surveys
promotion programme on Zoom: primary care weight management referral and delivery, found the first COVID-19 lockdown resulted
a service evaluation in primary and COVID-19 related weight gain has been reported. The 5 6
care. BMJ Nutrition, Prevention present study evaluated outcomes from a multicomponent in weight gain for up to 48% of respondents.
& Health 2021;0. doi:10.1136/ weight loss and health promotion programme in UK Primary care practitioners are in a unique
bmjnph-2020-000219 primary care, delivered remotely due to COVID-19 position to address weight management with
restrictions. patients. In the UK, options for primary care
► Prepublication history and Method Patients with obesity, type 2 diabetes or weight management include digital appli-
additional material is published pre- diabetes attended six 90 min sessions over 10 cations although more commonly involve
online only. To view please visit weeks on Zoom. The dietary component comprised
the journal online (http:// dx. doi. community- based, group lifestyle and weight
org/ 10. 1136/ bmjnph- 2020- a low- carbohydrate ‘real food’ approach, augmented management services delivered by the
000219). with education on physical activity, intermittent fasting, National Health Service (NHS), commercial
gut health, stress management, sleep and behaviour 7
1Bentley Village Surgery, change. Anthropometric and cardiometabolic data were providers or the voluntary sector. Usually,
Farnham, UK self- reported. Mental well- being was assessed with the these services are based on UK National Insti- http://nutrition.bmj.com/
2Independent Researcher, Warwick Edinburgh Mental Wellbeing Scale. Subjective tute for Health and Care Excellence (NICE)
Winchester, UK outcomes and participant feedback about the programme guidelines, which recommend that weight
3Independent Researcher, loss efforts focus on calorie deficit creation
London, UK were collected with an anonymous online survey.
Results Twenty participants completed the programme. through reduced energy intake and increased
Correspondence to Weight loss and improvements in body mass index, waist 8
physical activity. However, evidence indicates
Louise Walker, c/o Bentley circumference, systolic and diastolic blood pressure that carbohydrate restriction is also effective
Village Surgery, Bentley Village and mental well- being achieved statistical and clinical both via digital applications and in primary
Surgery, Farnham GU10 5LP, UK; significance. Mean weight loss (5.8 kg) represented a care and community settings to address excess on January 3, 2023 by guest. Protected by copyright.
lou@ louwalker. com 6.5% weight loss. Participants’ subjective outcomes
included weight loss without hunger (67%) and increased weight, cardiometabolic risk and glycaemic
9–15
Received 9 December 2020 confidence in their ability to improve health (83%). All control.
Revised 27 January 2021 participants reported the usage of Zoom to access the One proposed mechanism for the effec-
Accepted 2 February 2021 programme as acceptable with 83% reporting it worked tiveness of carbohydrate restriction for
well. weight loss is that it reduces insulin secretion,
Conclusion A multicomponent weight loss and health reducing its anabolic, fat- storing effects and
promotion programme with a low- carbohydrate dietary therefore facilitating oxidation of fatty acids
component, clinically and statistically significantly 16
improved health outcomes including weight status, blood from adipose tissue. Furthermore, because
pressure and mental well- being in a group of primary insulin stimulates glucose uptake, suppresses
care patients when delivered remotely. Further research is fatty acid oxidation and promotes fat and
warranted. glycogen deposition, hyperinsulinaemia
© Author(s) (or their effectively removes metabolic fuels from the
employer(s)) 2021. Re- use circulation, potentially driving hunger and
permitted under CC BY- NC. No 16
commercial re- use. See rights INTRODUCTION overeating. This could partially explain
and permissions. Published by Increasing prevalence of obesity and related the extended satiety often experienced
BMJ. metabolic dysfunctions such as type 2 diabetes with carbohydrate restriction that can lead
Walker L, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2020-000219 1
BMJ Nutrition, Prevention & Health
to spontaneous intermittent fasting by missing a meal, were not possible, although some commercial services BMJNPH: first published as 10.1136/bmjnph-2020-000219 on 15 February 2021. Downloaded from
35 36
extending gaps between meals or snacking cessation. A were delivered remotely. Remotely delivered primary
37
recent review of intermittent fasting protocols such as 5:2, care consultations are increasingly available and are
38
alternate day fasting and time-restricted eating found that acceptable and beneficial to patients and clinicians.
although weight loss can occur due to energy restriction, However, the authors are unaware of studies that have
cardiometabolic health benefits such as increased insulin explored the efficacy of remotely delivered, community-
17
sensitivity can occur independent of weight loss. based group weight loss interventions in primary care.
Carbohydrate restriction has also been associated with The present service evaluation appraises outcomes from
11 15
reduced blood pressure in primary care patients. a weight loss and health promotion programme deliv-
Rather than hypertension being addressed by weight loss ered as part of an ongoing initiative by the registered UK
per se, it has been speculated that dietary changes may charity the Public Health Collaboration (PHC) (www .
18
be responsible, and there is evidence that hyperinsuli- phcuk. org). The PHC delivers group programmes free
naemia increases sodium retention in people with T2D of charge, including within primary care, with the aim of
19 20
and hyperglycaemia. Reducing circulating insulin improving T2D management and weight status through
levels with carbohydrate restriction could contribute to carbohydrate restriction. Clinically significant weight loss
39
blood pressure improvement. and metabolic improvements have been achieved. PHC
With carbohydrate restriction, serum glucose can interventions vary in content, duration and structure but
drop rapidly and substantially, and blood pressure can typically involve six to eight 60–90 min sessions over 6–12
improve; therefore, some hypoglycaemic and antihyper- weeks for up to 20 people. The purpose of the present
tensive medications may need to be adjusted or discon- study was to evaluate outcomes from a six-session, 10- week
11 21
tinued. Medication review is therefore an important programme which, due to COVID-19 restrictions, was
consideration for patients following a carbohydrate- delivered on Zoom rather than face to face as originally
restricted eating pattern.11 21 intended. Because evidence suggests the combined
Anecdotally, carbohydrate restriction can improve effects of several healthy lifestyle behaviours reduces risk
22 40
mental well- being although the evidence base is weak. of mortality, the programme included education on
Certain dietary patterns can affect glycaemia, immune several lifestyle factors associated with health improve-
activity and the gut microbiome to influence mood and ment in addition to diet. Participants were patients from
23
mental well- being, and poor diet quality has been linked a group of general practices in Hampshire, UK. Primary
to depression and other severe mental illness mediated outcomes were improvements in weight status and mental
by dietary inflammation.24 25 The SMILES (Supporting well- being. Secondary outcomes were improvements in
the Modification of lifestyle In Lowered Emotional blood pressure and HbA1c. Subjective outcomes and
States) randomised controlled trial (RCT) found dietary participant feedback about the programme was assessed
improvement to be an effective treatment for major with an online questionnaire.
depression.26 http://nutrition.bmj.com/
There is no accepted definition of a low- carbohydrate
diet, a situation that has hampered synthesis of research METHOD
evidence. However, it has been suggested that <130 g/ Study design
day (26% daily energy intake (DEI)) denotes ‘low carbo- A before–after without control design was used to evaluate
27 28
hydrate’ ranging down to ≤20–50 g/day (<10% DEI) outcomes from a six-session, 10- week, multicomponent,
27
a ‘very low carbohydrate’ or ketogenic diet. Concern group- based weight loss intervention delivered on Zoom.
that sufficient dietary carbohydrate is required to supply Primary outcomes were weight loss (kg) and changes on January 3, 2023 by guest. Protected by copyright.
glucose for brain function can be addressed with recogni- 2
in body mass index (BMI) in kg/m , waist circumfer-
tion that the brain's energy requirement can be met with ence (cm) and mental well- being. Mental well- being was
the products of gluconeogenesis, glycogenolysis and with assessed using the Warwick Edinburgh Mental Wellbeing
29 41
very low carbohydrate intake, ketogenesis. While not Scale (WEMWBS) (online supplemental file 1), which
advocating carbohydrate restriction, NICE advises a low- is validated for measuring mental well-being in popula -
30 42
glycaemic index diet for T2D management, and some tions and is sensitive to change over time. Secondary
national diabetes organisations recognise carbohydrate outcomes were changes in systolic and diastolic blood
restriction as a therapeutic dietary option to improve pressure (mm Hg) and glycated haemoglobin (HbA1c)
29 31–33
glycaemic control and weight loss. The long-term (mmol/mol).
sustainability and safety of carbohydrate restriction is
34 Recruitment
debated, although a recent primary care service evalu-
ation reported successful compliance with concomitant In June 2020, patients from a four-practice, 32 000-
15 patient primary care network in Hampshire, UK, were
weight and cardiometabolic improvements over 6 years.
In 2020 in the UK, COVID-19 restrictions disrupted invited to a 60 min information session on Zoom about
opportunities in primary care for brief interventions to the Low Carb Real Food Lifestyle Programme (‘the
address excess weight and referral to weight management programme’). Each practice used their own recruitment
services. Face- to- face community- based interventions methods, which included email, text and promotion
2 Walker L, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2020-000219
BMJ Nutrition, Prevention & Health
via website and social media. Eligible participants were waist circumference regularly and to record other data BMJNPH: first published as 10.1136/bmjnph-2020-000219 on 15 February 2021. Downloaded from
those aged ≥18 years with T2D, pre- diabetes or who had such as blood pressure, HbA1c and serum lipids as avail-
been advised to lose weight, plus those living with or able, plus medications and any dose adjustments. Partic-
caring for someone in one of these categories. Following 43
ipants were encouraged to download the NHS app to
the information session, interested patients registered access their medical records or to request most recent
online using a Google Form, supplying contact informa- test results from their general practitioner. COVID-19
tion, reason for applying, general practice (GP) surgery, restrictions prevented participants accessing surgery
age group, sex and General Data Protection Regulation blood pressure machines, but they were encouraged to
consent. On the same form, all gave optional consent to buy their own. Plans to test for serum lipids and HbA1c
their data being anonymously analysed and reported. All at programme start and end were abandoned, although
also gave optional consent to their general practitioner participants supplied data if available. Test results from
being informed of their registration. within one calendar month of the last session were
Mechanism included. Participants emailed their completed prog-
Six 90 min sessions were conducted on Zoom fortnightly ress sheets to the lead author (LW) at programme end.
with participants divided into five groups. Each group had Mental well-being was measured at programme start and
two facilitators to ensure adequate technical and admin- end using the WEMWBS, a self-administered question-
istrative support for both facilitators and participants in naire. Answer sheets were emailed to LW. An anonymous
what was an unfamiliar medium for most people involved. post- programme online survey was developed to collect
Between sessions, participants could access optional extra participant feedback about their experience (online
support through private social media groups. Details supplemental file 5).
of group structure, facilitators and programme fidelity
control are outlined in online supplemental file 2. The Statistical analysis
programme used a low-carbohydrate dietar y component Statistical analyses were performed with R V.4.0.2.
augmented with sessions covering physical activity, sleep, Summaries of data at baseline and 10 weeks are shown
stress management, intermittent fasting, gut health and as mean, median and IQR (25th percentile, 75th percen-
behaviour change. Programme content is outlined in tile) for non- normally distributed continuous variables
box 1. (weight, BMI, waist circumference, mental well-being,
The programme was designed to provide enough blood pressure and HbA1c). Comparisons between data
information and physiology education to help partici- at baseline and 10 weeks of continuous variables were
pants understand, engage in and feel some control over made using the Wilcoxon signed-rank test for paired
their health. For the dietary component, there was no samples. A p value of <0.05 was considered statistically
calorie restriction, carbohydrate counting or set meal
plans. Instead, participants were encouraged to restrict significant. Only data for which there were matched http://nutrition.bmj.com/
sugar, processed foods and starchy carbohydrates such pairs were analysed.
as bread, pasta, rice and potatoes and to focus on eating
minimally processed foods to satiety. They were encour-
aged to experiment to discover what suited their pref- Box 1 Programme content for the Low Carb Real Food
erences and lifestyle and to make changes at their own Lifestyle Programme, July–September 2020
pace. Cooking from scratch was encouraged. Resources
provided included a one-page guide to low-carbohydrate ► Information session (6 July): introduction to a low carb/real food on January 3, 2023 by guest. Protected by copyright.
11 lifestyle, how/why it is helpful, what the course involves, medication
eating previously used in general practice, lists of foods
to enjoy and avoid and various online resources and adjustment guidance and registration administration.
recipe suggestions (online supplemental file 3). ► Session 1 (13 July): administration regarding data collection, goal
In the information session, participants were informed setting, hormonal model of obesity and T2D, recognising carbohy-
of guidance to consult their medical practitioner if they drates, insulin resistance and hyperinsulinaemia, getting started
were on medications, which could be affected by carbo- with low carb/real food, sample meal plans and food swaps.
11 21 ► Session 2 (27 July): avoiding processed food, food labels and shop-
hydrate restriction. This information was delivered by ping, further familiarisation with the low carb/real food approach
a general practitioner. It was emphasised in every session and goal setting.
that the programme constituted information not medical ► Session 3 (10 August): habit/behaviour change, lapse and relapse,
advice. how to deal with eating out, travelling, pressure from friends and
colleagues and goal setting.
Data collection ► Sessions 4, 5 and 6 (24 August and 7 and 21 September): physical
Data were collected before programme start and after activity, intermittent fasting, stress management, sleep, gut health,
the final session. Anthropometric and cardiometabolic and goal setting. (Facilitators covered these topics in whichever or-
data were self- reported using a personal progress sheet der suited their group’s needs.)
(online supplemental file 4). Specifically, participants ► Session 6 (21 September): review, celebration and next steps/look-
were encouraged to monitor and record weight and ing to the future.
Walker L, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2020-000219 3
BMJ Nutrition, Prevention & Health
All primary outcomes improved significantly BMJNPH: first published as 10.1136/bmjnph-2020-000219 on 15 February 2021. Downloaded from
(figure 2A–E). Mean weight loss was 5.8 kg (IQR 4.4–6.9),
p<0.001, representing a mean weight loss of 6.5% (IQR
2
4.5–8.2); mean BMI reduced: 2.0 kg/m (IQR 1.5–2.5),
p<0.001; mean waist circumference reduced: 5.2 cm
(IQR 3.8–7.3), p=0.006. Mean mental well-being score
improved by a significant (p=0.001) 6.5 units (IQR
3.0–10.0). A change of three units represents a change
42
likely to be noticeable and important to an individual.
Regarding secondary outcomes, blood pressure
improved significantly: mean systolic blood pressure
Figure 1 Flow of participants through the programme. reduced by 13.1 mm Hg (IQR 9.5–19.5), p=0.035, and
mean diastolic blood pressure reduced by 5.0 mm Hg
(IQR 2.0–6.5), p=0.042. Mean HbA1c improved by
RESULTS 9.1 mmol/mol (p=0.059). All participants for whom
Due to the range of recruitment methods employed by HbA1c data were available for analysis who did not start
the practices, the number of patients exposed to promo- with a healthy HbA1c had a reduced HbA1c after the
tional material cannot be ascertained. Data were collected intervention, with the highest starting values showing the
greatest reduction (figure 3).
from 20 participants; participants attended a mean of five Both of the two participants on insulin reduced their
sessions. Figure 1 shows the flow of participants through dosage, one by 100 units/day to 20. One patient had their
the programme. Table 1 shows participant characteristics gliclazide dose reduced after 1 month.
at baseline and reasons for registration.
Table 2 summarises outcomes. Insufficient data were Participant feedback
available for analysis of serum lipids. The feedback survey elicited 18 responses (online supple-
mental file 5). A range of subjective health improvements
were reported, as summarised in table 3, box 2.
Table 1 Participant characteristics at baseline and reasons Asked how confident they were that they would be able
for registration to maintain the changes they had made, 78% of partic-
N (%) ipants responded 7 out of 10 or above. Asked about
their experience of taking part via Zoom, 83% selected
Participants 20 (100) ‘worked well’; the remainder (17%) selected ‘not ideal
Female 17 (85) but generally ok’.
Male 3 (15) http://nutrition.bmj.com/
Glycaemic status DISCUSSION
T2D (HbA1c ≥48.0 mmol/mol) 10 (50) The present study evaluated outcomes from a six- session,
Pre- diabetes (HbA1c 42.0–47.9 mmol/mol) 1 (5) 10- week multicomponent weight loss and health promo-
Normal/unmeasured 9 (45) tion programme delivered by the PHC to primary care
Weight status patients on Zoom. The programme resulted in signifi-
2 cant weight loss and significantly improved BMI, waist on January 3, 2023 by guest. Protected by copyright.
Obese (BMI ≥30.0 kg/m ) 12 (60)
2 circumference, blood pressure and mental well-being.
Overweight (BMI 25.0–29.9 kg/m ) 5 (25) A number of subjective health improvements were also
2
Normal weight (BMI 18.5–24.9 kg/m ) 3 (15) reported including weight loss without hunger, decreased
Age group in years food cravings and increased health-related confidence.
40–49 4 (20) Participants found Zoom an acceptable way to access the
50–59 4 (20) programme. To the authors’ knowledge, this is the first
60–69 5 (25) evaluation of a remotely delivered group-based weight
loss or health promotion programme in primary care.
≥70 7 (35) These outcomes were achieved during the COVID-19
Reason(s) for registration pandemic when weight gain and increased anxiety and
5 6 44
Weight loss 20 (100) mental illness were reported.
Improved glycaemic control 12 (60) The programme encouraged participants to address
Reversal of pre- diabetes (only one was pre- 2 (10) several lifestyle factors that could have contributed to the
diabetic) significant outcomes. Relating to diet, notwithstanding
To support a family member 3 (15) the unknown carbohydrate restriction compliance, the
anthropometric and cardiometabolic outcomes align
BMI, body mass index; T2D, type 2 diabetes. with meta- analyses of RCTs comparing low-carbohydrate
4 Walker L, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2020-000219
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