Dr. Gotthelf cites our call for naturalistic studies to determine the effectiveness of weight loss programs and states that she offered such data, which we declined. We outlined very specific criteria for original research to be included in our review, one of which was that the data had to be published in a journal. We applaud Health Management Resources for collecting further data from observational studies and encourage the company to submit these findings for peer review.

Dr. Gotthelf states that we concluded that Weight Watchers was the most successful program. We did not state this, but rather concluded that Weight Watchers was the most rigorously tested program. We agree that a 15% loss of initial weight, as found in 1 Health Management Resources study, is more clinically significant than a 3% loss. However, most persons treated in medically supervised programs do not maintain a loss of 15% of initial weight at 2 to 3 years. In one of Health Management Resources' naturalistic studies, patients lost 19.2% of initial weight in 20 weeks but maintained a loss of only 7.3% at 3.4 years. This follow-up evaluation did not include 42% of the original sample, and the findings were not adjusted (using a baseline-carried-forward analysis) to account for the dropouts (1). Randomized comparisons of very-low-calorie diet regimens (as used in the Health Management Resources studies) and low-calorie diets (providing 1200 to 1500 kcal/d) have shown no difference in long-term weight losses (2), principally because of greater weight regain with the former approach.

Finally, Dr. Gotthelf states that we incorrectly estimated costs by including the price of meal replacements for medically supervised programs but not for programs that do not require meals to be purchased. This is a valid point. Our goal was to estimate the actual out-of-pocket costs associated with participating in each program. Clearly, participants must continue to purchase food when dieting. Some may spend approximately $80 per week on food, comparable with the costs of Health Management Resources' meal plan. Others, however, may spend substantially less. In reviewing Dr. Gotthelf's cited sources, we believe she has overestimated the usual costs of food.

In general, the programs we reviewed, including Health Management Resources, are among the better options available to patients who wish to lose weight. Many are members of the Partnership for Healthy Weight Management and provide appropriate information to potential clients (3). Our intention was not to disparage the important service provided by these programs, but rather to review the available evidence and to encourage publication of further research.