Reader Question: What’s the deal with Prescribe Fit

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This came up in our monthly subscriber Ask Me Anything and then from another email from reader Julie who wrote:

“I hurt my knee playing soccer. After a lot of of imaging I was told it wasn’t surgical. I asked for a referral to physical therapy and my ortho referred me to Prescribe Fit. I assumed it was physical therapy but it seems like it’s some kind of online diet thing. Can you tell me what’s going on?”

I can try! After digging around on their website, I found this, in their own words, Prescribe Fit is:

“an insurance-reimbursable weight-loss program with personalized one-on-one coaching designed specifically for orthopedic patients.”

Let’s examine the scientific basis they claim for this program. They claim:

“Studies prove a correlation between lifestyle, weight and musculoskeletal issues.”

Though they don’t actually cite any research to support this, they are correct that there is a correlation. What’ s more important is that they don’t point out that a foundational principle of research is that correlation does not imply causation, and that without controlling for confounding variables (including weight stigma, weight cycling, and healthcare inequalities) no conclusions can be drawn about the relationship of weight to health generally or musculoskeletal (MSK) issues specifically. I wrote about this in detail here. It seems to me that they are perhaps hoping that people don’t understand this and make the mistake of assuming that “prove a correlation” means that weight causes issues and weight loss solves them (which is NOT proven.) Next they say:

When it comes to losing weight, a 2019 Study by Duke showed that “generic advice doesn’t help patients drop pounds.” The study also found that “the physician should instead encourage patient participation in a specific program.”

The study they are referring to is “Provider Counseling and Weight Loss Outcomes in a Primary Care-Based Digital Ob*sity Treatment”  (As a side note, the trial whose data this study is using is a doozy that I may write more about later. For example, all subjects weighed less than 330 pounds because they didn’t bother to get a scale that could accommodate people whose weight was higher than that. Weight stigma layered on weight stigma.)

Prescribe Fit’s website doesn’t actually link to the study, they link to an article about the study. I think it may be helpful to note that neither of the quotes that they use on the website actually appears in the study. The first quote (“generic advice doesn’t…”) is just the title of the article they link to. The second quote (“the physician should instead encourage patient participation in a specific program”) was given to the cited article’s author by study co-author Gary Bennett. Bennett is  a professor of psychology at Duke and the only co-author of the study who disclosed conflicts of interest – he has equity in COEUS Health which undertook at least one clinical trial to test a specific weight loss program. (The trial appears to have cost over $575k and was completed in 2019, but has not posted results that I could find.) He also serves on the scientific board of Nutrisystem which also offers this type of program. The article doesn’t mention these conflicts of interest.

There is a reason that quote doesn’t appear in the study itself. The actual study that the article on the Prescribe Fit website is discussing tracked only 134 people over just 12 months, and a quote that does come from the study itself is “the counseling groups in this secondary analysis were not randomly assigned and we cannot conclude a causal relationship between counseling and weight.” (emphasis mine.)

I would argue that the study conclusion was also… less robust than Dr. Bennett’s quote would suggest:

“Provider counseling that focuses specifically on engagement in a weight loss intervention may enhance weight loss outcomes relative to more general weight loss advice. Counseling that enhances patients’ perceptions of empathy may be most beneficial for patients’ weight loss.” (emphasis mine)

Note the use of the word “may”…twice.

So what is Prescribe Fit promising?

According to their “How it works” video they can help participants

“lose weight for good”

Given that claim, I scoured their website for data showing people having lost a significant amount of weight and then maintaining that throughout their lifespan.

I did not find anything that would suggest, let alone support, that. What I found was:

"We have over an 80% retention for 9+ months to complete lifestyle modification. Average weight loss of 5.4% in just 16 weeks which drastically improves MSK issues and patient’s day-to-day life.”

I have to ask why, if they have retention data for 9+ months, are they only giving 4 months of weight loss data? What happened during the other 5 months for the 80% of clients they retained?

They have some testimonials. Only two of them that I saw included how long the person had been involved in the program – one was just 100 days and one was 6 months. Their “how it works” video says

Patients should commit to at least three months, but it typically takes one year to fully transform your lifestyle. Then each patient is matched with a personal health coach who is available for weekly 15 minute phone calls in-app messaging and personalized advice

Remember again that all they are offering is average weight loss of 5.4% body weight in four months. (Given that it is an average and we don’t have a table of data giving us basic information like the number of people and the amount of weight that was lost, we are missing a lot of context here. This could mean that most people lost about 5.4% of body weight, it could also mean that a few people lost a large amount of weight but most participants experienced far less than 5.4% etc.)

Remember that research that tested the claim that 5-10% body weight loss creates health benefits found that:

“Across all studies, there were minimal improvements in these health outcomes and none of these correlated with weight change…we uncovered no clear relationship between weight loss and health outcomes related to hypertension, diabetes or cholesterol” I wrote about this study here.

Further, they offer no research that I could find to support their claim that 5.4% body weight change “drastically improves MSK issues and patient’s day-to-day life.”

Let’s examine this idea. It means that if someone comes in weighing 400 pounds, they are told that their body size is the problem and if they lose 21.6lbs (making them 378.4lbs,) it will drastically improve MSK issues and their day-to-day life. But if someone comes in who weighs 378.4lbs, they are told that their body size is the problem and that if they lose 20.4lbs, making them 358lbs, it will drastically improve MSK issues and their day-to-day life. But if someone comes in who weighs 358lbs….

And this continues until when? What is considered the magical weight at which a patient is no longer just 5.4% body weight loss away from “drastic improvement” and they get actual healthcare for their MSK issues? I wrote about this fallacy in detail here.

They aren’t particularly specific about the program’s content, but everything I saw suggested that it’s based on the old “eat less, exercise more” paradigm with a bit of stress management and social connection thrown in. I did notice some of what I would consider more serious red flags (and content warning for weight loss/disordered eating behavior content, feel free to skip the rest of this paragraph.) The testimonials say some things that are concerning to me for disordered relationships with food and exercise. For example, one says “[my coach] teaches me what I can eat and what I can’t eat,” another mentioned “cutting foods out,” and another mentioned working out multiple times a day, each day. In general, the program seems to be based on having a coach who gives standard intentional weight loss advice to a client who has been given a Bluetooth enabled digital scale on which they weigh-in five times a week with their weight transmitted to their coach and their referring doctor.

Given that research over the last century has shown that with behavior-based weight loss interventions like this almost everyone loses weigh in the short term (about the first year) and almost everyone gains it back within 2-5 years, absent some serious data showing that this program actually offers long-term success, I have questions about their ability to help patients “lose weight for good.”

This is especially concerning given the harm of weight cycling and possible damage to relationships with food, movement, and bodies, including disordered eating and eating disorders.

Unless I’m missing something, they don’t have any research showing that their program is likely to create long-term, significant weight loss.

To go back to Julie’s original question - this does not appear to be physical therapy, so if you ask for physical therapy and get referred to this, that, to me, would warrant some serious questions.

So that’s the patient side. In part 2 we’ll look at the prescriber side of their site.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.