Nutrisystem

Nutrisystem, headquartered in Fort Washington, Pennsylvania, is a commercial provider of weight loss products and services. Initially, the company offered weight loss counseling and products in brick and mortar centers. In 1999, the company moved to a direct-to-consumer business model, selling its products and programs on the Internet and through a call center via 1-800 numbers. Nutrisystem’s programs have been sold on the QVC television home shopping network since 2001 and in Costco stores since 2009. The company entered the retail arena in 2012 with the launch of its "Everyday" line of breakfast and snack items in Kroger grocery stores. In April 2013, the company began selling its five-day "Jumpstart" line in Walmart stores.

Products
The company states that its mission is to provide a weight loss program based on quality foods and a nutritionally balanced meal plan. The foundation of all Nutrisystem programs is the home delivery of portion-controlled entrees and snacks. Customers supplement these packaged foods with grocery foods, including vegetables, fruits, and dairy items. When followed, the diet is low in glycemic index and provides nutrition consistent with the Dietary Guidelines for Americans – 2010. Resources are also available for increasing physical activity and obtaining behavioral support.

Meal plans
Separate plans are offered for women and men, at calorie levels that support a weight loss of 1–2 lb/week (approximately 1200 calories per day for women and 1500 per day for men). Approximately 52%, 26%, and 22% of calories come from carbohydrate, protein, and fat, respectively. All plans contain at least 28 g of fiber per day, and have no more than 85 g of sugar, 170 mg of cholesterol, and 2300 mg of sodium per day.

Under its current program, Nutrisystem Success, the company offers four categories of weight loss plans: standard plans for women and men, Nutrisystem D (a plan designed for people with diabetes or prediabetes that meets the nutrition guidelines of the American Diabetes Association ); Nutrisystem Silver (a plan targeting heart health); and Nutrisystem for Teens (a plan for adolescents age 14–17 years old who are above the 85th percentile for body mass index). Many special dietary needs can be accommodated (e.g., low-sodium, vegetarian), whereas others cannot (e.g., allergies to peanuts or soy, celiac disease).

Food
The Nutrisystem program provides over 150 menu choices in four categories: breakfast, lunch, dinner, and snacks/desserts. Most options are shelf-stable products which include bars, muffins, pretzel snacks and pancake mix, as well as microwavable soups and dinner entrees. All shelf-stable microwaveable entrees are developed through retort preparation, which uses heat and pressure to cook food in a strong, sealed package (like a can or pouch). This preparation method allows for safe holding at room temperature and minimizes the need for added preservatives or sodium. Nutrisystem also has a line of frozen food choices available called “Nutrisystem Select.”

The Nutrisystem products provide approximately 60% of daily calorie needs. The remaining 40% of daily calorie intake comes from grocery foods, which the customer purchases separately. These grocery food additions include fresh fruits and vegetables and low-fat dairy and protein sources. The program provides specific guidance on how to choose and when to use these grocery additions.

Physical activity
Although dietary intervention is the primary focus of the program, Nutrisystem encourages customers to increase their physical activity. "My Daily 3," Nutrisystem's exercise guidelines, encourages customers to complete at least the equivalent of three 10-minute bouts of moderate-intensity activity per day. Customers who choose to set exercise goals are given targets for aerobic and strength training activities at the beginner, intermediate, and advanced levels. Online resources in support of customers’ activity goals include sample workouts, articles, discussion boards, tips, and exercise trackers. Nutrisystem recommends that customers consult with a health professional before beginning a new fitness program.

Behavioral support and additional resources
Because Nutrisystem is not offered in brick-and-mortar centers or clinics, behavioral support is not available in face-to-face interactions. The program, however, includes several resources intended to promote motivation, behavior change, and success.

Counseling
Customers have free access to trained counselors via telephone, online chat, and email. Nutrisystem D customers, additionally, are given access to certified diabetes educators, who are registered nurses or registered dietitians. Contact with counselors is initiated by the customer and is not regularly scheduled as a required part of the program.

Self-monitoring tools
Research on weight loss programs has consistently found that self-monitoring (i.e., keeping track of weight-related behaviors) is related to losing more weight. Nutrisystem provides paper, online, and mobile device applications to encourage customers to record their food intake and physical activity. Customers can also keep track of their progress (weight loss and changes in measurements) on the company’s website.

Behavior modification guide
“Mindset Makeover,” Nutrisystem’s behavior modification guide, is used in all programs except Nutrisystem for Teens. This guide covers 13 topics – related to making mental and behavioral changes in support of weight control – that are intended to be completed over 13 weeks. Customers can access the guide in its interactive form online or download a copy of the guide in .pdf format. Alternative behavioral materials were developed for the Nutrisystem for Teens program. Separate guides are available for the teen participant and the responsible parent or guardian.

Peer support
The Nutrisystem website supports an online community, which allows members to participate in discussion boards and chats with their peers or to keep a blog if they wish to do so. Participation in the online community is not a required aspect of the program.

Additional resources
Other resources available on the member website are largely educational or intended to help customers adhere to program recommendations. They include: nutrition, health and wellness articles; daily tips; online recipe center; printable list of recommended grocery foods; comprehensive dining out guides

Cost
The company's weight loss plans include 28 days’ worth of breakfast, lunch, dinner, and snack entrees, and are sold on three tiers, which Nutrisystem calls Basic, Core, and Select. The Basic-level plans include a pre-configured menu of shelf-stable Nutrisystem foods, which is not customizable. The Core-level plans allow customization of shelf-stable foods and include free access to counselors. The Select-level plans additionally include frozen foods. At the time of writing (January 11, 2013), 28-day packages ranged in price from $230 for the Basic version of the Nutrisystem Success plan for women to $290 for the Select version of the Nutrisystem D plan for men. Note that Nutrisystem customers must purchase additional grocery foods (e.g., fruit, vegetables, dairy) to complete the meal plans.

Discounts and promotions are frequently offered as an incentive to join the program. A common promotion is the inclusion of multiple weeks of “free” food typically divided among a corresponding number of months. Customers who enroll in the “auto delivery” option (i.e., subsequent shipments of food are delivered without further action by the customer) receive free shipping and a discount of approximately 10% off the month-to-month price. A long-term contract is not required, but purchasing fewer than two orders on “auto delivery” will result in a retroactive charge for any auto-delivery discount plus the cost of shipping on the first order.

Individual testimonials and celebrity endorsements
For the majority of the company's existence, Nutrisystem’s results were communicated solely in the form of before-and-after photos and testimonials from individual customers.

Research on program components
Increasing the structure of a low-calorie diet has been found to improve weight loss when compared to a low-calorie diet of self-selected foods. Use of portion-controlled foods and structured meal plans are two means to that end, both of which are incorporated into Nutrisystem's weight control programs. The primary concern related to this approach is long-term sustainability. No studies have compared long-term adherence to structured, versus unstructured, low-calorie diet plans.

Nutrisystem's low-calorie diet is also low in glycemic index. Whether reducing the glycemic index of a low-calorie diet improves weight loss has been the subject of considerable debate. The empirical evidence is mixed. Whereas a meta-analysis showed a small but significant weight loss advantage of approximately 2 lb, several larger studies that were subsequently published found no additional weight loss benefit. For persons with diabetes, however, the evidence suggests a greater reduction in HbA1c with a low-glycemic index diet, compared with a higher-glycemic index diet that produces the same weight loss.

Research on Nutrisystem programs
Two randomized controlled trials have examined the effects of Nutrisystem D on weight and other cardiovascular risk factors among people with type 2 diabetes. The first of these studies, published in 2009, was a 3-month comparison of Nutrisystem D plus weekly counseling sessions versus a control intervention that included education and support sessions related to diabetes Those who received the Nutrisystem D intervention achieved an average weight loss of 18.1 lb (representing a 7.1% reduction in body weight), compared with 1.3 lb in the control group. They also achieved significantly more favorable changes in HbA1c (−0.88% vs. +0.03%), fasting blood glucose (−35 vs. -7.4 mg/dl) systolic blood pressure (−5.9 vs. +3.6 mmHg), triglycerides (−44 vs. +6 mg/dl), and total cholesterol (−22.3 vs. -1.8 mg/dl).

The second randomized trial compared Nutrisystem D with a structured program of diabetes self-management education. All participants had type 2 diabetes and all received their intervention in nine sessions delivered over 6 months. As in the previous study, changes in weight, diabetes control, and other metabolic outcomes were significantly more favorable in the group that received Nutrisystem D.

A third clinical trial examined the effects of the Nutrisystem D program on multiple glycemic outcomes among people with type 2 diabetes. Using continuous glucose monitoring, subjects were found to have significantly lower average blood glucose and have a significantly smaller standard deviation of blood glucose values (indicating less variability in blood glucose) during consumption of Nutrisystem D, compared with their usual diet. Additionally, participants experienced less hyperglycemia, without significantly increasing the occurrence of hypoglycemia, during consumption of the Nutrisystem D meal plan.

Nutrisystem researchers have examined the "real world" effects of the company's weight loss programs by analyzing customer data. Customers who entered their weight online at the time of initial program enrollment and again after 3 or 6 months were found to lose an average of 18.2 lb (an 8.3% reduction in body weight) at 3 months and 27.2 lb (a 12.1% reduction) at 6 months. Of note, the sample size fell substantially from 3 months (n = 103,693) to 6 months (n = 32,280). Thus, these results are more representative of a per-protocol analysis than to an intent-to-treat analysis.

Maintenance of weight loss
Reviews of the Nutrisystem program criticize the company’s approach as not conducive to long-term weight control. For example, the review on webmd.com states, “Dieters may only experience success while they are ordering the prepackaged foods because once they are on their own, they are faced with the real world of cooking, meal preparation, and issues they are not prepared to handle because they were not addressed on the plan." In response to concerns such as these, Nutrisystem began offering “transition” plans in 2011. The idea behind these plans is to help customers continue following the principles of the Nutrisystem program (portion-controlled, low-GI eating) after they no longer purchase pre-packaged foods from the company.  This is achieved by allowing customers to select partial programs (e.g., exclude pre-packaged dinners from their orders) and offering portion-control tools and recipes that are consistent with the nutrition profile of the main weight loss program.  Weight loss maintenance results from customers who use these programs have not yet been published.