Unclear evidence on the cost-effectiveness of distance lifestyle counselling for weight control in the workplace

Being overweight is bad for your health, but finding the time and resources to address this can be difficult. Using distance communication technology, such as e-mail or telephone, can help make person-to-person counselling more accessible to working adults.

This isn’t the first time we’ve looked at interventions of this nature at The Lifestyle Elf, but it is the first time we’ve discussed an economic evaluation. The cost of these interventions is crucial in the decision of whether or not they should be provided. While there is growing information about the efficacy of these interventions, there is still only a limited number of economic evaluations in this area. A recent trial, based in the Netherlands, contributes to this literature.

A headset and a keyboard

Participants were randomised to receive a lifestyle intervention with either telephone or internet based support.


The economic evaluation was carried out alongside a clinical trial with 1386 participants. Seven companies were recruited and employees were eligible for the trial if they had a BMI above 25. Participants were randomised to one of three arms, but all received self-help brochures on lifestyle change in an attempt to aid recruitment. Those in the two intervention arms additionally received a lifestyle intervention program consisting of ten modules. One group received the program in written form and received counselling by telephone, the other accessed the program through an individualised program website and received counselling by email.

The primary outcome was change in body weight at 24 months. A secondary outcome was quality adjusted life years (QALYs), as measured using the EQ-5D and Dutch tariff values. The costs of the intervention were recorded and costs associated with health service use and absenteeism were collected using participant diaries.


The study obtained complete baseline and follow-up data from 120 individuals in the control arm, 140 in the telephone arm and 125 in the internet arm. However, the authors’ primary analysis used imputed values increasing the numbers to 448, 453 and 450 respectively. The main analysis found no significant difference in either the change in body weight or quality of life in the intervention groups compared with the control group. Mean average values for costs and outcomes in each arm are shown in the table below.

Control Telephone Internet
Weight loss (kg) 1.1 1.5 1.9
QALY gain 1.85 1.85 1.86
Intervention cost (€) 0 201 177
Total cost (€) 2480 2832 2494

The authors also carried out a number of sensitivity analyses. They ran the analysis without imputed values and found more favourable results, though they note that self-selection plays an important role in this result. The analysis was also carried out from the perspective of the employer, accounting only for the costs and benefits relevant to them, and results indicated that the internet intervention may be cost-effective.


The authors conclude that

The lifestyle program with phone counseling was not proven to be cost effective. The program with e-mail counseling showed some promising results but its cost-effectiveness was uncertain.

Clearly, willpower and motivation remain key to success. Those who completed the modules and remained engaged with the study achieved greater weight loss than those who did not. Unfortunately, adherence to both interventions was limited.

Adherence and satisfaction were higher in the telephone group

Adherence and satisfaction were higher in the group receiving counselling by telephone


The authors found no significant benefit in terms of QALYs. However, one might expect this. The EQ-5D has been shown to be sensitive to the effects of obesity, but not to those of pre-obesity (Sach et al. 2007); usually defined as a BMI above 25. One might also expect the main health benefits of being of ideal weight to be observed years in the future, through a reduced risk of cardiovascular disease, diabetes and other non-communicable diseases. Furthermore, if someone has been overweight for many years their health may be affected for some time to come, even despite weight loss.

While the authors conclude that they cannot prove either intervention cost-effective, one should note the low cost of the intervention and the observed weight loss in the ‘internet’ arm, which are promising. It also seems possible that the provision of such an intervention could be a cost-effective strategy for an employer. It’s likely that studies will need longer follow-up times and better adherence to ‘prove’ – one way or another – the cost-effectiveness of interventions of this nature.


van Wier, M. F., Dekkers, J. C., Bosmans, J. E., Heymans, M. W., Hendriksen, I. J M., Pronk, N. P., van Mechelen, W. and van Tulder, M. W. Economic evaluation of a weight control program with e-mail and telephone counseling among overweight employees: a randomized controlled trial. The International Journal of Behavioral Nutrition and Physical Activity 2012; 9(112). [Pubmed]

Sach, T. H., Barton, G. R., Doherty, M., Muir, K. R., Jenkinson, C. and Avery, A. J. The relationship between body mass index and health-related quality of life: comparing the EQ-5D, EuroQol VAS and SF-6D. International Journal of Obesity 2007; 31: 189-196. [Pubmed]