Effect of JumpstartMD, a Commercial Low-Calorie Low-Carbohydrate Physician-Supervised Weight Loss Program, on 22,407 Adults

Background Commercial weight loss programs provide valuable consumer options for those desiring support. Several commercial programs are reported to produce ≥3-fold greater weight loss than self-directed dieting. The effectiveness of JumpstartMD, a commercial pay-as-you-go program that emphasizes a low-to-very-low-carbohydrate real-food diet and optional pharmacologic treatment without prepackaged meals or meal replacement, has not previously been described. Methods Completer and last observation carried forward (LOCF) of clinic-measured weight loss (kg) in 18,769 female and 3638 male JumpstartMD participants. Results Completers lost (mean ± SE) 8.7 ± 0.04 kg, 9.5 ± 0.04% with 44.5 ± 0.5% achieving ≥10% weight loss at 3 months (mo, N = 14,999 completers); 11.8 ± 0.1 kg, 12.6 ± 0.1% with 66.4 ± 0.6% achieving ≥10% weight loss at 6 mo (N = 11,805); and 11.5 ± 0.2 kg, 12.0 ± 0.2% with 57.6 ± 0.9% achieving ≥10% weight loss at 12 mo (N = 8514). LOCF estimates were −6.5 ± 0.03 kg, −7.2 ± 0.03% with 27.1 ± 0.3% achieving ≥10% weight loss at 3 mo; −7.7 ± 0.04 kg, −8.5 ± 0.04% with 36.3 ± 0.3% achieving ≥10% weight loss at 6 mo; and −7.7 ± 0.1 kg, −8.4 ± 0.1% with 34.6 ± 0.3% achieving ≥10% weight loss after 12 mo. Frequent health coach meetings was a major determinant of weight loss, with women and men attending ≥75% of their weekly appointments losing 8.8 ± 0.04 and 11.9 ± 0.1 kg, respectively, after 3 mo, 13.1 ± 0.1 and 16.5 ± 0.3 kg after 6 mo, and 16.5 ± 0.3 and 19.4 ± 0.8 kg after 12 mo. Phentermine and phendimetrazine had a minor effect in women only at 1 (6.1% greater weight loss than untreated), 2 (4.1%), and 3 mo (1.2%), but treated patients showed longer enrollment than nontreated during the first 3 (females: +0.4 ± 0.01; males: +0.3 ± 0.04 mo), 6 (females: +1.1 ± 0.04; males: +1.0 ± 0.1 mo), and 12 mo (females: +2.7 ± 0.1; males: +2.4 ± 0.2 mo). JumpstartMD produced generally greater weight loss than published reports for other real-food and prepackaged-meal commercial programs and somewhat greater or comparable losses to meal replacement diets. Conclusion A one-on-one medically supervised program that emphasized real low-carbohydrate foods produced effective weight loss, particularly in those attending ≥75% of their weekly appointments.


Introduction
Seventy percent of US adults are overweight or obese [1], 42% report trying to lose weight, and 23% report trying to maintain weight annually [2]. Five to ten percent weight loss produces clinically significant health benefits [3], with even greater health benefits likely to accrue with greater weight loss [4].
Americans spend 2.5 billion dollars annually on commercial weight loss programs, broadly categorized as calorie-Slimming World and Rosemary Conley are available as online programs in the United States. In Europe, Australia, and some US states, partnerships exist between national payers and these programs for patients seeking weight loss. Several commercial programs have been shown to produce twice as much weight loss as those administered through standard healthcare settings [6,7], and ≥3-fold greater weight loss than self-directed dieting [8,9]. e odds for >10% weight loss in obese NHANES participants trying to lose weight were 70% greater for those that joined a commercial weight loss program vs. self-directed weight loss [10].
JumpstartMD's approach to weight management uses a real-food low-to-very-low-carbohydrate diet and one-onone, personalized instruction and support from trained health counselors in the setting of a medical clinic. It is an alternative to other commercial calorie-counting and meal plan programs that use group education and group support.

Methods
JumpstartMD is a pay-as-you-go weight management program supervised by physicians that emphasizes the benefits of a low-carbohydrate diet and healthy lifestyle.
rough weekly one-on-one clinic visits personalized to fit each person's life and by emphasizing fresh, whole, nonpackaged foods, JumpstartMD's health coaches provided accountability and support, nutritional guidance, behavioral modification, and fitness recommendations to achieve sustainable wellness goals. Because the program is medically supervised and a licensed healthcare practitioner is present in every center, JumpstartMD is also capable of making adjustments in diabetes, blood pressure, and other medications as well as offering FDA-approved weight loss medications for interested and eligible patients. Participants attended the program for as long as they wished.
Weight loss was achieved through nutritional guidance, tracking, and meal planning to create caloric deficits for sustained weight loss without the use of prepackaged foods or meal replacements. Clinicians prescribed a recommended nutritional guide path for members early in their program that eliminated consumption of grains, starches, and sugars while limiting consumption of carbohydrates to typically under 50 grams a day from low glycemic (nonstarchy) vegetables and fruits. Dietary carbohydrate recommendations varied by participant based on starting weight and degree of insulin resistance as noted from baseline laboratory tests. Structured meal plans were prescribed using portion sizes. Following the recommendations provided, participants' energy intake derived from carbohydrate would typically fall between 10% and 20%, and sometimes as low as 5%. While JumpstartMD does not specifically "count calories" or discuss "calories consumed," properly followed, the program would typically generate a dietary caloric deficit on the order of 500 to 1000 Calories or more per day.
Dietary compliance was tracked using the program's pocket-sized forms or the participant's own mobile phonebased software, which were reviewed weekly with their health coach or clinician. Dietary carbohydrate intake was monitored by measuring and recording amounts of approved fruits and vegetables consumed. Dietary protein consumption was similarly monitored by measuring and recording consumption of foods with high protein content, including meats and seafoods, dairy products, and legumes. Healthy dietary fats were tracked and monitored only when the food's primary macronutrient composition was fat (i.e., as in the case of butter, cream, olive oil, nuts, seeds, and avocado). Dietary tracking was an important component of the intervention but was not collected in a standardized manner for data analysis.
Physical activity recommendations generally correspond to current Centers for Disease Control (CDC) recommendations while also supporting the patient's own physical activity goals. Weights were measured directly at each clinic visit in light clothing without shoes (Tanita digital healthcare scales; Arlington Heights, IL). Participants were provided a macronutrient tracking tool to help them record their daily consumption of allotted carbohydrate, protein, and healthy fat servings. Participants reviewed their progress in achieving their macronutrient recommendations with their individual JumpstartMD clinician or health coach via weekly one-on-one in person visits. e program has expanded from a single clinic in 2007 to thirteen clinics across the greater San Francisco Bay Area.

Statistical Analysis.
Anonymized data were provided to an independent statistician not previously associated with the commercial program for analysis. Attendance was calculated at each visit as the ratio of the number of follow-up appointments attended divided by the expected number of weekly appointments (i.e., number of days since baseline starting date divided by seven). For each individual, average number of days since baseline, weight loss, % weight loss, BMI change, attendance, and ≥5% and ≥10% weight loss were calculated within each two-week interval since baseline. Mean changes from baseline ± SE were calculated over all subjects within each interval and plotted vs. the average follow-up duration. Regression analyses were used to assess the relationship between weight loss vs. attendance, baseline BMI, sex, and age. Analysis of covariance was used to assess weight loss differences between patients on and off obesity drugs, with and without adjustment for enrollment duration. Results are presented with standard deviations given in  ). High-attendance completers were defined as patients attending at least 75% of their weekly appointments, as has been defined by others [14,22,30]. All analyses were performed using JMP version 13.2.0 (SAS institute, Cary, NC). Race, socioeconomic status, and comorbidity data were not collected.
Results are presented in as forest plots with diamonds representing the average differences between JumpstartMD and other commercial programs (identical size for each comparison) and 95% confidence intervals for the differences. Standard errors (SE) were taken from the published reports, calculated as SD/N 0.5 , or calculated from the 95 percent confidence intervals as (upper-lower bound)/ (2 * 1.96). When SEs were not otherwise available, the standard deviations were estimated from the relationship between mean weight change (independent variable) and the standard deviation of weight change (dependent variable) from the JumpstartMD dataset, using the coefficients of Table 2. Different coefficients were used for estimating "LOCF" and "completer" standard deviations. Median weight losses [11,14,32] were increased by 5.2% for weight change (∆kg), 2.1% for percent weight change (∆%), and 4.4% for BMI change (∆kg/m 2 ) corresponding to the JumpstartMD difference between mean weight loss and median weight losses.

Statistical Methods, LOCF.
e primary outcome for comparing JumpstartMD to other commercial programs was LOCF because it encapsulates both retention and weight loss success. Differences in design and analyses have stymied prior efforts to synthesize commercial weight loss results by meta-analyses [61]. Our analyses adjust for these differences by tailoring the JumpstartMD sample to the recruitment specifications and follow-up duration of each published report. Specifically, adjusted JumpstartMD LOCF weight losses (mean ± SE prediction ) were calculated to corresponding to the average baseline BMI, age, and proportion of men of each commercial program.
is was done by (1) restricting the Jump-startMD data to the commercial study's BMI recruitment range and (2) applying multiple linear regression to the restricted JumpstartMD LOCF data with age, male sex, and sex-specific baseline BMI effects as independent variables. Prediction formulas for the expected value and the prediction standard errors were then evaluated using the average age, sex, and BMI for the reported study (Table 1). e mean differences between JumpstartMD and the reported commercial studies and the standard error for the difference were estimated by standard methods.
e JumpstartMD LOCF analysis included only those subjects who chose to continue their program beyond their initial assessment visit. Some published studies assigned zero weight loss to patients without any follow-up data, affecting the denominator but not the numerator of the average LOCF. Ahern [25], and 2.2% standard rate assumed to apply to Collins et al. [45]. Avery et al. reported 997 of 1020 Healthy Living Pharmacy patients and 5306 of 5482 general practitioner patients returned for follow-up weigh-ins [16]. erefore, to achieve comparability to the JumpstartMD results, the reported estimates from other studies were adjusted upwards by decreasing their denominator by the proportion of the sample that lacked follow-up (assumed to be 7% unless otherwise stated [6,12,20,37]). An anomaly was Mitchell et al. who reported 25.7% non-follow-up among 1605 Medicaid recipients, which may be due to the lower socioeconomic status or racial composition of their sample [14]. To obtain corresponding samples, JumpstartMD LOCF data were calculated for patients attending ≥4 weeks for comparison with Meffert and Gerdes [27]. e recruitment criteria for subsidized physician referrals were generally ≥30 kg/m 2 , but exceptions could be made per the physician's discretion [20]. erefore, for comparisons with subsidized physician referrals, the JumpstartMD sample included randomly selected overweight patients (25 < BMI < 30) to match their reported recruitment proportion (assumed to be 4% as reported by Dixon et al. [12] unless otherwise specified).
Follow-up duration was taken as that described by the commercial study, i.e., 84 days if described as 12-week Journal of Obesity  Journal of Obesity 5   Journal of Obesity weight loss, 91.25 days if described as 3-month weight loss, or if otherwise described (e.g., 12 meetings or until a 5-week hiatus [11]). Although the 12 weekly Weight Watcher or Slimming World meetings represent only 11-week differences, patients apparently had 14 weeks to complete the course [20,21] and therefore were compared to 12-week JumpstartMD weight changes.

Statistical Methods, Completers.
JumpstartMD completer weight losses were compared to those reported for other commercial studies when matched for follow-up duration, recruitment BMI range, baseline age, proportion of males, and sex-specific baseline BMI effects as described in Methods section. Specifically, we (1) selected the Jump-startMD subset corresponding to the BMI range of the other commercial program, (2) divided the JumpstartMD records into 2-week intervals, (3) obtained the regression coefficients for expected weight loss and SE prediction within each interval by least-squares regression with age, sex, and sex-specific effects of baseline BMI as independent variables, (4) within each interval, used these regression coefficients to calculate the expected weight loss and SE prediction corresponding to the average baseline age, sex, and BMI of the other commercial program, and (5) used linear interpolation to estimate weight loss for the designated length of follow-up from the proximal 2-week intervals. Comparisons are presented as "(JumpstartMD ± SE prediction vs. other commercial program ± SE)." In some cases [13,43,44,50,60], weight loss for completers was calculated from baseline observation carried forward (BOCF) by inflating the BOCF weight loss by the ratio of the total sample divided by the number of patients providing data (i.e., zero weight loss in patients lost to follow-up increases the denominator but not the numerator in calculating mean weight loss). Completers were usually defined as participants with a weight measurement at a specified follow-up duration; however, Stubbs et al. defined "completers" as completing 10 th , 11 th , or 12 th visit by the 14 th week [20] and the 20 th , 21 st , 22 nd , 23 rd , or 24 th visit by the 28 th week [21]. Aherns et al. defined completers as completing 12 visits or the last observation until a 5-week hiatus in attendance [11]. Jump-startMD completers were correspondingly defined for comparisons with these studies. Additional adjustments for the inclusion of non-obese patients and the estimation of 12week follow-up for Weight Watchers and Slimming World were as described above for LOCF.

Meta-Analysis.
Pooled estimates were calculated as weighted averages of the inverse of the standard error 2 (fixed effect meta-analysis).

Results
Of the 24,395 patients in the electronic patient base, we excluded 114 for errors in the admission date (prior to Jan 1, 2007) or missing sex information and 59 for missing baseline body weights. Of the 24,222 patients remaining, we excluded 1815 (7.5%) patients who received an initial evaluation and weight loss recommendations but chose not to enroll with the program, leaving 22,407 patients for the analysis of weight change.
Women represented 83.8% of the participating patient population. On average, they were slightly younger than the   . JumpstartMD patients had a financial enticement to terminate the program early, which is not the case for clinical trials or subscription weight loss programs. Specifically, clinical trials subjects consent to participate in a no-cost program for a specified duration and subscribers prepay for a specified program length. In contrast, JumpstartMD patients pay a significant fee to receive their initial evaluation and recommendations and separately pay significant fees to participate on a month-to-month basis without obligation for as long as they perceive benefit from the program.  Figure 1(a) shows that approximately twothird of the 18,769 women (67.2%) and 3638 men (65.6%) attended ≥3 months, 53.4% of the women and 49% of the men attended ≥6 months, 45.2% of the women and 39.4% of the men attended ≥9 months, and 39.2% of the women and 31.8% of men attended for ≥one year. Regression analyses showed that during the first 3, 6, 9, and 12 months, women were enrolled an average ± SE of 1.2 ± 0.5, 4.9 ± 1.2,  Journal of Obesity 10.3 ± 2.0, and 16.4 ± 2.7 days longer than men, respectively, and each year of age was associated with 0.17 ± 0.01, 0.47 ± 0.04, 0.81 ± 0.06, and 1.12 ± 0.08 days additional enrollment, respectively. e effects of BMI on enrollment duration were not significant at 9 and 12 months. Figure 1(b) displays the intensity of participation as measured by clinic attendance. Among completers, the percent of patients attending at least 50%, 60%, 75%, and 90% of clinic appointments was 95.1%, 90.8%, 78.0%, and 45.9% during the first three months, respectively; 89.5%, 82.7%, 62.6%, and 24.6% during the first six months, respectively; 80.3%, 68.9%, 45.1%, and 27.6% during the first nine months, respectively; and 66.5%, 53.3%, 30.8%, 8.3% for the year (percentages are the cumulative average attendance through the patient's last visit). Regression analyses showed that during the first 3, 6, 9, and 12 months, percent attendance averaged ± SE 2.10 ± 0.43%, 4.0 ± 0.65%, 3.49 ± 0.93%, and 5.40 ± 1.17% higher in women than men, respectively, and averaged 0.30 ± 0.03%, 0.76 ± 0.0.04%, 1.09 ± 0.06%, and 1.34 ± 0.07% higher per kg/m 2 increment in BMI, respectively. Age was not significantly related to attendance. Figure 2 presents the average weight loss in completers regardless of their level of active participation or starting weight. At the end of the first month, the patients lost an average of 4.37 ± 0.02 kg and 4.86 ± 0.02% of body weight and 1.57 ± 0.01 kg/m 2 of BMI. Nearly one-half (46.59 ± 0.33%) had lost over 5% of their body weight. At the end of 13 weeks, the patients lost an average of 8.66 ± 0.04 kg body weight, representing a 9.47 ± 0.04% reduction, and a 3.12 ± 0.01 kg/m 2 drop in BMI, with 86.3 ± 0.31% attaining ≥5% and 44.51 ± 0.45% attaining ≥10% weight loss. After 6 months (26 weeks), the completers had lost 11.81 ± 0.08 kg, 12.57 ± 0.08% of baseline weight, and 4.28 ± 0.03 kg/m 2 . Ninety percent (89.73 ± 0.37%) had lost over 5% and 66.37 ± 0.58% had lost over 10% of body weight. ereafter, weight loss leveled off, with those completing 9 months (39 weeks) averaging 12.39 ± 0.13 kg weight loss, 12.96 ± 0.12% weight loss, and 4.52 ± 0.05 kg/m 2 reduction in their BMI from baseline. Five percent or greater weight loss was attained by 87.13 ± 0.52% of the sample and 10% or greater weight loss by 65.32 ± 0.74% of completers. Similarly, at one year, average weight loss was 11.45 ± 0.16 kg, 11.98 ± 0.16%, and 4.22 ± 0.06 kg/m 2 with 81.37 ± 0.70% losing ≥5% body weight and 57.57 ± 0.89% weight loss losing ≥10% body weight. Figure 3 shows that the amount of weight loss was strongly related to baseline BMI. Figure 4 shows that weight loss success depended on regular meetings with the patients' health counselor. Figure 4(a) shows the relationship between attendance and weight loss for months 1 through 9 and at one year. At each time point, greater attendance was significantly associated with greater weight loss. Moreover, there was a significant curvilinear relationship between attendance and weight loss, which became progressively greater over time. is meant that the difference between low and high attendees became greater over time, such that at 40% attendance, weight loss plateaued after 4 months, whereas at 80% attendance, weight loss continued longer into the year. ose meeting with their health counselor nearly every week showed the greatest total weight loss and the longest period of active weight loss.

Comparison of LOCF with Other Commercial Programs.
Figures 5 through 15 present the individual weight loss differences between JumpstartMD and other commercial studies when matched for follow-up duration, recruitment BMI, baseline age, proportion of males, and sex-specific baseline BMI effects. Negative differences for Δweight loss, Δ% weight loss, and ΔBMI represent greater weight loss in JumpstartMD patients. e average fixed effect meta-analysis estimates of the weight loss differences between JumpstartMD and these other programs are presented in Table 3. JumpstartMD weight losses were significantly greater than the average published losses over all calorie/food/meal plan (Weight Watchers, Slimming World, Rosemary Conley, and Itrim), and Internet programs (Biggest Loser Club) for all measures of weight loss (Table 3, Figures 5-15).
Except for percent weight loss at 52 weeks, JumpstartMD weight loss was also greater than those reported for prepackaged meals (Table 3). Figure 16 (top panel) shows that one-year LOCF percent weight loss was greater for JumpstartMD than Jenny Craig self-paying customers for their Platinum (49% greater percent weight loss) and Rewards program (30% greater [24]). ey also reported the Rewards program percent weight loss by final week of attendance [23]. JumpstartMD LOCF weight loss was over 30% greater through the 39th week and 13% greater between weeks 40 and 52.
JumpstartMD weight loss was almost always greater than those reported for meal replacement programs in completers due to the inclusion of a very large sample of Nutrisystem completers [51]. JumpstartMD kg weight loss was 18% greater than reported for 103,693 Nutrisystem patients at 3 months and 9% greater than reported for 32,280 patients at 6 months ( Figure 11). ese data are not included in the LOCF analyses or the completer's analysis at 1 year. e figures suggest that Medifast 5&1 plans produced significantly less weight loss than JumpstartMD in the study by Shikany et al. [56], greater weight loss in the study by Coleman et al. [28], and mixed results in the study by Davis et al. [54]. Medifast 4&2&1 plan and Health Management Resources (combination of meal replacement and prepackaged meals) showed significantly greater weight loss than JumpstartMD.

Favors JumpstartMD
Mean ± SE Figure 9: Mean LOCF weight loss difference between JumpstartMD and other commercial programs as measured by percent attaining ≥10% weight loss. Positive differences designate greater JumpstartMD weight loss. See legend to Figure 5 for further explanation.
weight loss [64]). Even greater average weight losses were attained in patients who attended at least 75% of their week appointments with their personal healthcare coach after 3 (women: 8.8 kg; men: 11.9 kg), 6 (women: 13.1 kg; men: 16.5 kg), and 12 months (women: 16.5 kg; men: 19.35 kg). Consistent with other reports [42], the weight loss tended to be rapid initially, diminishing thereafter, and then plateau as compensatory mechanisms that tend to increase food intake and reduce weight loss kick in. However, Figure 4 showed weight loss continued to be accrued throughout the year at higher participation levels. is is consistent with other reports showing the importance of patient involvement [ [11,19], sex [11, 12, 15, 19-22, 29, 30], and initial body weight [11,12,20,21,26,42] affect weight loss success. e greater weight loss in heavier subjects may account in part for the greater weight loss success in men given that the sex difference largely disappeared for percent weight loss (Figure 2).
A one-on-one physician-supervised program that provides individual health counselors and nutritional advice must necessarily be more expensive than group-based and Internet-based therapies, and this additional cost warrants scrutiny in terms of weight loss success. Moreover, although important health benefits accrue for 5% or 10% weight loss,
Our comparative analyses were restricted to the intervention arm of the randomized trial (representing only 0.3% of the published patient population) and longitudinal patient data (99.7% of the published patient population) because we believe these uncontrolled values accurately reflect the treatment effects. Specifically, in the absence of illness or behavioral change, large cohorts of individuals do not lose weight over time, with most Western adults gaining 0.2 to 2.0 kg per annum [66,67]. None of the wait-listed or usual diet control arms of commercial programs RCT show any significant weight loss, i.e., weight change from baseline: − 0.3 ± 0.35 kg [59], +0.16 ± 0.88 kg [33], +0.84 ± 0.41 kg [42], +0.36 ± 0.24 kg [44], − 0.25 kg [58], and − 0.6 ± 0.71 kg [52]. In addition, clinical trial participants are not representative of the general population, do not pay for their own treatment (selection bias), and are subtly coerced to participate and not dropout (performance bias). Hence, the call for "naturalistic studies" of large cohort followed prospectively that report retention rates and weight loss at discontinuation [68].

Pharmacotherapy.
Unexpectedly, phentermine and phendimetrazine had, at best, a modest weight loss effect in the context of the low-calorie low-carbohydrate diet and behavioral intervention, perhaps because it is not a central part of the medically supervised lifestyle modification program and not central to a participant's success. Its principal benefit was prolonging exposure to the weight loss intervention leading to additional weight loss consistent with nonpharmacologically treated patients.

Limitations.
Although participants tracked their diets using supplied forms or their own mobile phone software and shared this information with their health coach, these data were not collected for data analysis. us, there is no statistical verification of their carbohydrate intake or dietary caloric deficit.
e superiority of JumpstartMD vis-à-vis other commercial programs does not exclude the possibility that patients choosing JumpstartMD may be more predisposed to weight loss (i.e., self-selection). Comparisons between JumpstartMD and other programs may be somewhat skewed by the fact that JumpstartMD participants could afford to pay $350 to $400 per month and the costs associated with a healthy low-carbohydrate diet and physical activity. Monthly Dansinger [34] Dansinger [34] Dansinger [34] Heshka [8] Marrero [39] Marrero [39] Stubbs [20] Stubbs [21] Collins [44] Collins [44] Collins [45] Collins [45] Collins [45] Collins [45] Rock [48] Rock [48] Foster [52] Moldovan [  pricing often diminished after 4 months on program because members had an option to transition from a weekly to a twice monthly for weight loss or maintenance or later for a monthly visit structure at a lower monthly fee for maintenance only. We do not have information on the income levels or health literacy of the JumpstartMD population, which could contribute to weight loss differences of the figures. e data available for statistical analyses also lacked detailed medical record information; however, medical histories were collected and reviewed by the clinical staff and adjustment made to the dietary prescription as appropriate. Although a low-carbohydrate intake was generally prescribed, the exact carbohydrate goals varied by participant in accordance with their weekly clinical assessments and interviews to judge the patient's tolerance to the diet. Eliminating the possible effects of self-selection would require a randomized trial, an approach that has largely failed to distinguish weight loss differences between other commercial programs [33,37,42,68]. We also caution that these analyses rely on previously published reports, which may not necessarily represent current practices in other commercial programs.

4.3.
Conclusions. JumpstartMD appears to provide greater weight loss than most other published commercial programs (i.e., Weight Watchers, Slimming Ahern [11] Aston [32] Jolly [37] O'Neil [40] Pinto [41] Pinto [41] Heshka [8] Jebb [6] Bye [17] Aveyard [43] Bye [17] Lavin [18] Stubbs [20] Lavin [18] Stubbs [21] Jolly [37] Jolly [37] Itrim Hemmingsson [26] Hemmingsson [26] 12 wk Coleman [29] Coleman [29] Smith [59] Smith [59] 91.1 ± 0. World, Rosemary Conley, Jenny Craig, and Nutrisystem), presumably because it provides resources necessary for comprehensive individualized nutritional and behavioral counseling in a medically supervised environment and because the low-carbohydrate dietary approach may promote greater satiety and voluntary limitation of caloric intake [69]. Increased protein intake associated with a low-carbohydrate diet may also have contributed to increased satiety [70]. Accessibility to the Jump-startMD program is dependent upon financial resources. It addresses the weight loss needs of those patients requiring or desiring greater personal attention than provided in less-expensive group instruction or online programs. Commercial weight loss programs offer a spectrum of personal support. Programs like Weight Watchers and Slimming World would be more easily scaled to address the weight loss needs of sizable overweight population at lower socioeconomic status. In addition, programs such as Weight Watchers may provide more pounds lost per dollar spent [71]. However, JumpstartMD may be a better option for those valuing high touch, individualized attention and greater total weight loss combined with the associated health and aesthetic benefits. Moreover, pounds per dollar spent may be too narrow a criterion given that obese patients incur 46% higher inpatient costs, 27% more physician visits and outpatient costs, and 80% higher prescription costs than normal weight individuals [72].

Conflicts of Interest
Dr. Bourke is the Chief Medical Officer for JumpstartMD. Dr. Williams was commissioned to perform the analysis and assist in manuscript preparation but has no other financial interest in the research or conclusions. Dr. Williams takes responsibility for the analyses performed. Dr. Morton has no financial interest to disclose.  [23]. JumpstartMD samples were selected to correspond to the Jenny Craig analyses.