Where did PROGROUP come from?

We’re 18 months into the study and “PROGROUP” is proving to be quite a journey of discovery about attitudes to obesity! The origins of PROGROUP now seem half a lifetime away, but perhaps that just confirms that you have to take a “long view” in research. So here’s the long view on PROGROUP.
At the time, I was still in my training, and I was surprised that medicine seemed to offer little more than “palliative care” for the treatment of type 2 diabetes (a prominent obesity-related disease), trying to slow the condition by reducing complication rates, but not fundamentally addressing the main underlying cause – obesity.
Another obstacle was that for many years obesity was not taken seriously. Society had viewed obesity in negative terms and stigmatised and blamed affected individuals. As I point out to students, the management of chronic diseases, including smoking-related diseases and diabetes, is not facilitated by apportioning personal blame; and obesity is no different. The idea that there is lack of willpower over a self-inflicted or “voluntary” condition is a related misconception. A dressing down for personal failings and complacency is not an approach to be found in any taxonomy of proven behaviour change techniques. In contrast, there is a compelling body of evidence encompassing genetics, neuroscience, endocrinology, epidemiology and behavioural sciences, that provides a very different narrative on the causes weight gain and its perpetuation.
A few years later, but still on my learning curve, during a Wellcome Travelling Fellowship, I asked my then mentor what interventions were worthwhile in the treatment of severe obesity? “Well, Jon, one thing you have to have for sure is access to bariatric surgery”, was George Bray’s first comment. “But don’t you find most people would prefer alternatives?” He nodded, agreeing that more effective alternatives were required, including better behavioural, dietary and drug treatments. Finding these treatments was the mission of Pennington Biomedical Research Center.
Back in the UK, we were considering the commissioning of group-based weight management intervention for our “Tier 3” clinical service, and I asked “Is there any evidence that this model works?” We had to conclude that there was little evidence. No research had considered how behavioural change interventions are optimised and delivered in the tier 3 setting. Of course, there probably wasn’t any realistic alternative to group-based care, given the high demand faced by our service. Around this time, I had the good fortune (showing the role that serendipity often plays in research) to bump into Mark Tarrant at a Pen CLAHRC meeting, and we realised that we shared similar interests. Also serendipitously, I had been working with Dawn Swancutt on an unrelated project, and she was remarkably unfazed by the daunting prospect of assembling a programme grant. That made me feel better about it all. The final programme of research represents an outstanding collaboration and shared endeavour of a fantastic research team. Several years later, a lengthy process culminated in the successful funding of the PROGROUP study by NIHR. I admit I had to read the award letter twice! This is the first study designed to examine and optimise the specific processes by which behavioural treatment for severe obesity is delivered in the NHS, and it represents a major investment by NIHR.
After the first 18 months of PROGROUP, we have learned that the formal study and optimisation of complex interventions in the clinical setting of NHS Tier 3 weight management services is full of challenges. We are now identifying solutions to such challenges in the second work package, which involves a fully randomised controlled feasibility trial (fRCT) of the intensive group-based behavioural intervention versus usual care at three weight management centres. In routine clinical care, usually we can find some way to accommodate a patient who is too frightened to be weighed, or too immobile to attend regularly, or has too far to travel, is too anxious to attend a group event, unwilling or unable to join in a supervised gym or swimming session, has reading or language difficulties, can’t access online educational content, can’t start our programme on this or that day because of other social/domestic or work-related commitments, or whose attendance is somehow undermined by other factors or competing priorities. Accommodating such uncertainties is the daily bread and butter of running a Tier 3 weight management service, but all of this is more complex in the more rigorously controlled environment of the RCT. As a result of such experiences, the requirement for researchers to run a feasibility trial before a full-scale RCT seems profoundly wise, as is the importance of the strongest possible multidisciplinary research team including PPI.
The main signal emerging from the feasibility trial so far is that some flexibility and several adaptations may be required to deliver the main trial in the real-world setting of NHS Tier 3 weight management services. PROGROUP addresses several basic research questions about group-based delivery of behaviour change, but it will be complemented by many other studies on new drugs and other specific treatments. This is an exciting time in this area of medicine and gives much hope. At long last, it’s good to see that the quest for effective treatment of severe obesity is receiving much more attention.

Article by Jonathan Pinkney.
To find out more about the PROGROUP study please visit:
https://www.plymouth.ac.uk/research/primarycare/obesity/progroup