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WEIGHT MANAGEMENT

Pharmacists are emerging as the weight management specialists, providing advice, treatments and support for the long-term maintenance of weight loss. Stephen Kreitzman and Valerie Beeson offer some background information to help tie together the complex issues surrounding weight management

The primary fuel for normal meTabolism is sugar. This simple and well-established fact provides the key to an understanding of the complex and at times confusing issues associated with managing body weight.

Sugar
‘sugar’ is a confusing term right from the start, since in common usage sugar generally refers to sucrose, the usual sweetener found on the table. in fact, however, there are many different sugars. The lactose in milk and the fructose sugars found in fruit and honey are very common in our diets. a healthy, normal diet should generally provide about 60 per cent of its calories from sugars in one form or another. The form in which sugars are presented to the body does make a difference. This difference, however, is usually more important in the digestive tract. before a sugar can enter the bloodstream, it must be digested (broken down from complex forms such as polysaccharides or even 2 unit sugars such as sucrose or lactose) into single unit sugars and then transported actively by carrier mechanisms across the gut membranes. What actually enters the blood, therefore, are primarily the simple sugars, glucose, fructose and galactose. if we are slow or unable to digest these complexes of sugars, they are considered fibre and provide different benefits to the body other than calories. for calories, the important sugar is glucose.

Glycogen
since glucose is critical for normal energy provision in our cells, there is necessarily some storage and there are three primary storage sites. Glucose is stored in the human body in the liver, in muscles and, very important for the understanding of weight management, in the fat cells. When glucose is stored at these sites, it is stored in the form of a complex polymer of
glucose called glycogen. Glycogen fact: There is a lot more of it in the fat of overweight people than in normal weight people. it is stored in a very hydrated form – 3–5 parts of water per part of glycogen. This means that a pound of glycogen stored in the body actually weighs between 4–6lb on the scales. Conversely, using a pound of glycogen for energy will show up as a 4–6lb weight loss. The water is simply excreted.

Weight loss
Tracking the weight of a dieter losing weight on a lowcarbohydrate, low but constant calorie intake shows very rapid weight loss initially, which very smoothly slows as less and less of the daily fuel used is glycogen. after the glycogen is essentially depleted, the subsequent weight change per day is virtually linear, reflecting the constant 3,500-calorie deficit per pound of fat weight lost and the constant intake. The consequences of the early loss of glycogen and associated water are familiar to most dieters. The initial days of weight change are heady since glycogen, a carbohydrate contributing four calories per gram to the daily deficit, will need a deficit of only 1,800 calories to use up a pound of glycogen and release another 4–5lb of water weight. This makes weight loss seem easy. it is an illusion. not only is glycogen repleted after the restriction is finished, but if the reintroduction of carbohydrates to the diet is not done properly, the repletion can actually deposit excessive glycogen and water. This would be a weight gain.

Body weight or energy stores?
it is necessary to distinguish changes in body weight from changes in the energy content of the body. failure to do so has led to laxative abuse and diuretic abuse. but as we have just discussed, loss of substantial amounts of water weight can be achieved by carbohydrate restriction. it can even be achieved by intensive exercise with several pounds of sweat lost. making changes in the glycogen and water stores of the body can be dramatic, but should not be confused with a loss of weight that reduces the energy reserves stored in the body. While it is essential, regardless of the methods employed, to produce a calorie deficit and subsequent weight reduction, to first deplete the glycogen reserves, it should be clear that drastically reducing the intake of carbs will produce an initial weight loss regardless of the calorie content of the food consumed. it should be just as clear, however, that if the calorie content of the food is in excess of that used, the overall energy stored in the body will be increased even while there may be a measurable and possibly substantial weight reduction on the scales. This
is the same as a secured bank loan. it will be paid back. The lost water weight will be easily regained. in order to reduce the energy stores of the body it is absolutely necessary to consume less calories than are used.

Nutrients in a low-calorie regime
There is no secret or magic to weight management. The calories eaten have to be considerably less than those being used for a sustained period of time. but professionals understand that continued health of the patient requires the patient to consume all the essential nutrients necessary for life and health. This becomes increasingly difficult as the amount of food consumed is reduced. We eat collections of plant and animal material every day and if we maintain a varied selection of foods, we can feel reasonably confident that we are getting the complete array of essential nutrients. The plants and animals we choose for food, however, each have some of the essential nutrients required by man, but none have them all. To get the right amounts for sustained health it is absolutely essential that we eat in excess of 1,200 calories. not because there is some metabolic danger related to the low calories, but simply because eating foods with lower calorie totals cannot provide all the nutrients needed by people.

The myth
experience showed that dieters eating less than about 1,200 calories a day frequently became ill. so a myth arose that dropping calories below about 1,200 in order to lose weight was unhealthy. it was, but not because the calories were low. a fat person has an enormous store of calories available. no additional calories are really needed while dieting. Supplementing with the missing nutrients, however, permits dropping the calorie intake much further without harm, as long as there are reserves of fuel left in the body. Fuel for the body is limited to glucose (and stores as glycogen) and fat. an obese individual has about 37,000 calories in reserve for each stone of excess weight and therefore has no realistic need to eat more. They just need to get the essential nutrients. When these come from a nutrient-complete formula food, the results are ideal: complete nourishment in minimal calories, only those contributed by the essential nutrients.

Fat versus carbohydrate for energy storage
it is fortunate that we store most of our excess calories as fat rather than as carbohydrate. 7,000 excess calories stored as fat adds an extra 1kg to our body weight. storing the same excess calories as glycogen and water would add close to 10kg. it does mean, however, that lowering the body content of energy stored as fat is necessary and requires a larger calorie gap to achieve than is necessary for glycogen.

Weight loss services in pharmacy
Dealing with weight management as a professional service in the pharmacy is considerably more effective when dieters are made aware of the differences between weight loss and loss of fat. Dieters need to understand the components of their lost weight – glycogen and water usage before fat. They need to understand how to restore the correct physiological balances after a period of calorie restriction to minimise recidivism. They need to understand that excessive protein intake during dieting may inhibit the resorption and utilisation of excess skin.
They should understand that the health outcome after a period of calorie restriction depends on the quality of nourishment available during calorie restriction. simply considering calories and not the nutrient needs of the body will undermine overall health. and the pharmacist needs to understand that in the very fat person, the first 10 per cent or so of body weight lost is primarily glycogen, with minimal fat. The 10 per cent target is usually the beginning of the depletion of the excess energy stored in the body fat, not the endpoint.
Pharmacists are emerging as the weight management specialists, providing lifestyle advice, effective treatments and support, and follow-on help for the most difficult aspect of managing weight: the long-term maintenance of weight loss.

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HEALTHY WEIGHT MANAGEMENT

Messages abound in the media today about nutrition and body weight. But often these messages are more about controversy than provision of information. Dr Stephen Kreitzman and Valerie Beeson elaborate on the subject of weight management from beyond the hype

PHARMACY IS ONE OF THE FEW PLACES LEFTTHAT THE
public can rely on for responsible information. With regard to food, nutrition and especially weight management, the media appears to have totally abandoned its duty for accountability. The messages frequently given to the public by print and electronic media regarding the food they are eating are reckless, sensationalised (definition: “to cast and present in a manner intended to arouse strong interest, especially through inclusion of exaggerated or lurid details”) and apparently designed to be primarily entertainment rather than informative and
helpful even when presented in a ‘documentary’ format.
What constitutes a ‘healthy’ diet
A ‘healthy’ diet is one that provides all of the components that human beings are required to recycle from eating the plant and animal materials we call food. Consider, for the moment, a carrot. A carrot was part of a living plant. It is made up of thousands upon thousands of different chemical components. If we had an unlimited budget and the best analytical capacity possible, we could isolate and identify each and every chemical that comprises ‘the carrot’. It would make a very long list indeed. The list, however, would not completely match the list of required substances for humans. In order for humans to remain healthy, and support growth and development when necessary, repair tissues, provide protection and all the other requirements for life, the elements for humans need to be provided, not carrots. Carrots are considered healthy foods, but a diet that contained only carrots would quickly lead to ill health and an early demise.

The same can be said of every other item we use for food. We could develop the list for potatoes, beef, milk, soy beans – every common plant and animal substance we use for food. Not one of these ‘foods’ would, by itself, match all the human needs. In order to provide humans with all the required substances – vitamins, minerals, trace elements, essential amino acids and essential fatty acids – the nutrients, we have to mix and match from the available lists to match our requirements in both quality and quantity.
Each of the lists represents the chemical components of the food item. Regardless of whether the food was grown locally or in a remote part of the world, whether it was grown organically’ or with the aid of technology, or frozen, canned or dehydrated, the list is still an inventory of chemicals. They are not necessarily chemicals added by the food industry. They are the chemicals required to be a carrot, potato or whatever. Some of those chemicals are useful for our nutrition, but most are not and some are
The Pharmacist The Pharmacist ?? even harmful. It can’t be avoided. It is true of every food. They only way to provide a healthy diet is to combine foods to provide all the essential nutrients and do it from a varied selection so that the good stuff is available in necessary quantities and the bad stuff is kept to low enough levels that our physiology can cope with them.
Not many people select their dinner choices on the basis of nutrient need; nevertheless, even if we don’t know whether our food has enough selenium today, as an example, we still require selenium. It is the same selenium that can be provided as an isolated component in a nutritional supplement. Under ordinary conditions, supplements may not be necessary. When people eat a varied, mixed diet, the ordinary foods will supply the nutrients needed. Under conditions of food restriction, however, as would be common in a weight reduction diet,
the nutrients will not all be there in enough quantity. The nutrient density in common foods makes it impossible to construct a nutrient complete diet with total calorie intake below 1,200. To accomplish this at 1,200 calories requires a computer and the necessity to consume some specific foods not usually found on family menus in the UK.
The editor of one of the glossy slimming magazines once argued that the only nutrients of concern were a short list of vitamins for which a daily intake has been widely published. Regardless of that ill-informed position, the human body will be compromised if not supplied with all the essential nutrients. Supplementation is almost always required during weight reduction or the dieter will be malnourished. It is the lack of available nutrients in restricted weight reduction diets that has led to the myth that a low calorie intake is hazardous.
The idea that extra calories are required during weight reduction can readily be seen as ludicrous when you consider that the one item the obese patient has in store in great excess is calories. The great bulk of extra fat is a massive store of extra calories: 35,000 calories are available from each stone of extra fat weight. The reason dieters were compromised was because they were depleted in essential nutrients. Provide all the essential nutrients and exogenous calories are unnecessary. The only calories required are the calories provided by the
essential nutrients – primarily the essential amino acids and the essential fatty acids. Provide the nutrients and the dieter will remain perfectly healthy as long as there is a reserve of fat. In fact, if the nutrient content provided is complete quantitatively as well as qualitatively, the dieter will be healthier whilst dieting than at any time in the past.
What is a ‘healthy’ degree of weight loss?
Weight loss is important if weight is in excess. It is possible to debate the value of weight loss for cosmetic reasons, although one should not really devalue the quality of life issues associated with even a minimum amount of excess weight in our modern society. Far more important to health professionals, however, is the understanding that excess weight is a major health hazard. The precipitous increase in type 2 diabetes is a direct result of the pandemic of overweight and obesity. Excess weight is a cause of insulin resistance and if chronic will often lead to diabetes. Up to 80 per cent of people with type 2 diabetes will die from cardiovascular disease. It has become fashionable in recent years to denigrate BMI in favour of other simpler measures. Although calculating BMI is a challenge, it is valid. BMI risks were derived from a massive database by life insurance companies, who will not risk their money when BMI exceeds critical values. The negative consequences of elevated BMI begin even within the so-called normal range and rise exponentially into overweight and obesity. And it is misleading to believe that only excess fat weight is detrimental. The facts prove otherwise. Massive excess weight of muscle is as risky to health as excess fat. Professional athletes are not especially long-lived; in fact, the converse is usually true. The healthy range of weight to attain is within the normal BMI range of 20–25, regardless of the pre-diet weight. Having said that, however, every pound of weight lost reduces the medical risk and therefore although it may not always be possible to reach the ideal, it is still worth going part way. It is time to stop looking for ways to violate the natural laws. Calories count. The number of calories used by the body has to be matched with the calories eaten for weight to be stable. Eat in excess, regardless of whether the calories are carbohydrate, fat, protein or alcohol, and weight will be gained. Eat fewer calories and weight will be lost. That is fewer calories than are used, not just fewer calories than normally eaten. It appears to be widely believed that reducing intake by 200 calories a day will result in more than 20 pounds of weight loss in a year.
Obese people are eating hundreds if not thousands of excess calories daily. Reducing this excess by a few hundred calories may slow the weight gain a little, but will certainly not cause weight loss. To lose weight in a realistic time frame, it is essential to reduce the calorie intake as much as is consistent with a complete supply of nutrients. To lose weight it is necessary to eat less. The value of exercise in weight management is seriously over-rated. To use up the calories in an average size chocolate bar, it is necessary to run about three miles (without a calorie laden sports drink).
If we are to really deal with the plague of obesity, it is time to go back to fundamental physiology and stop looking for scapegoats to blame and wishful thinking for miracle solutions.

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MANAGING OBESITY BY CHALLENGING ADDICTION

Obesity has been linked to addiction.

What does this mean for the future of weight management?

Weight loss by total food replacement (the elimination of all food from the diet) is seen by some as a draconian and unnecessary approach to the management of obesity. When trying to devise a successful weight loss programme, the optimum approach would appear to be fairly straightforward simply reduce the daily caloric intake to a point below the level of calorie utilisation. In layman’s terms. just eat less. Indeed, there are many different approaches currently available, all based around the notion of eating less: low carb, low fat, calorie counting, behaviour modification (smaller plates) etc, not to mention the plethora of meal replacement programmes in which a small amount of non-formula foods may be consumed. Why then, would anyone need to use a total food replacement formula (very low calorie diet) in order to lose weight?

It is true that each of the available approaches to calorie restriction can have successful outcomes, even in cases where the logic of a diet plan is spurious or medically dubious, or possibly even in violation of the laws of thermodynamics. Whatever the given approach of a specific diet plan might be, it will Lead to weight loss if it reduces a dieter’s daily calorie intake to a point below the body’s daily requirement.

Unfortunately, nothing in life is ever that simple. Despite a bewildering selection of diet programmes, self-help books, drugs, even surgical interventions, the increase in overweight and obesity continues almost unabated. Weight regain is virtually universal regardless of the method of weight loss or the will of the dieter. Even post-surgical weight regain remains one of the bewildering frustrations of the field. The consequences of relentless gain of weight, however, in terms of medical co-morbidities, healthcare costs and personal quality of Life, make it necessary to find answers.

Obesity and addiction

The solution to obesity should be trivial, as we have already seen. All dieters have to do is just eat Less.

In addition, many people can and do control their eating behaviour and never appear to be in danger of escalation into obesity.

For those who do become obese however, their food behaviour often displays the compulsions and cravings of an addiction. Indeed, it is when food consumption is put into the context of other addictive behaviours that the nature of the problem becomes clear. The link between addiction and obesity 15 even being exploited in the search for drugs to combat obesity, as can be seen in the 30 July 2010 report in The Lancet on the use of naitrexone in conjunction with bupropion as a weight loss treatment.

How robust is the parallel between drug addiction and obesity, and are there insights from the research into addiction that can guide our treatment of overweight? Not all people who are exposed to habit-forming drugs become addicted, just as not all people exposed to high-fat, high-calorie foods become obese. Vast numbers of people consume moderate amounts of alcohol and do not advance to alcoholism. Many people are able to stop smoking as they take on board the health consequences of continuing.

Drugs and food appear to activate common reward circuitry in the brain. The brain naturally produces opiates: drug-like chemicals that cause pleasure sensations and are linked to addictions. Animal studies show that these chemicals can be a trigger for sweet, fatty cravings. And consuming such foods make the brain produce even more of the chemicals (as shown, for example, in studies of rats fed chocolate milk). When the brain’s normal opiate production was blocked, rats chose their normal feed over previously tempting sweets.

Drewnowski tested this approach on 41 women (bingers and normal eaters). They were offered their favourite foods. from pretzels and jelly beans to chocolate chip cookies and chocolate ice cream. Half received injections of naloxone, a drug used to treat heroin overdose because it blocks brain opiate receptors. The rest were given a placebo of saline.

Naloxone made the bingers eat considerably less – 160 fewer calories per meal, as Drewlowski reported in the American journal of C!nicol Nutrition. Their chocolate consumption dropped in favour of lower fat foods like popcorn. When asked to rate their favourite foods again, chocolate was rated lower than before. Significantly however, the non-bingers weren’t affected, a finding that might limit the widespread efficacy of the drug combination referred to above. If a person’s obesity is related to compulsive behaviour then this research is very encouraging. For others, however, its effectiveness will be extremely limited. In other words, it may only help those patients it can help.

If we accept a component of addiction in food abuse and ultimately obesity, then we need to recognise that the most powerful long term treatment for addictions is complete abstinence from the addictive substance. A reformed smoker is someone who does not smoke. A reformed alcoholic is someone who does not drink.

Alcoholics note that it is easier to draw a line between zero drinks and one drink, than between the first and second or even the sixth and seventh. There is an exact parallel with seriously overweight people: the introduction of almost any food can trigger the need for substantial food consumption. Unfortunately for the overweight, total abstinence from food is generally not considered feasible or even survivable. As a result, this most powerful tool for the control of food abuse is usually overlooked.

From a biological point of view, however, it is important to recognise that the human body does not survive on food, it Survives on nutrition. We require a constant supply of a very specific list of chemicals (nutrients) to sustain ourselves. These chemicals are typically ingested in the food we eat. Because there is no single food that exactly matches the nutritional needs of a human being, it is important that we receive our nutrition from a diverse range of foods. For an addict who abuses food, this presents a serious problem one that the mantra ‘just eat less’ completely fails to address.

Total food replacement programmes

The advantage of a total food replacement programme is that nutrition is provided by an engineered formula that is nutritionally complete. allowing the dieter to remove the addictive substance (food) from his of her fife while the weight is lost. The value of a total food replacement formula programme in the treatment of overweight and obesity should now be obvious. Total food replacement is the only means by which those who are subject to food abuse may avoid the addictive stimulus that perpetuates their weight problem.

This begs the question of how to proceed once the excess weight has been lost. Although the smoker should not return to cigarettes, and the alcoholic should not begin drinking again, the idea of avoiding traditional foods for life is a disturbing prospect, and one that no one would actually promote. The concept of permanently denying the pleasures of the table is unlikely even for the most food-averted of the population: itis inconceivable for the food addicted. There will inevitably be a food future, with the possibility (even probability) of weight regain. The availability of total food replacement formulas for future weight correction is likely the factor that protects against addiction transfer, an overwhelming and destructive consequence of weight reduction surgery.

Addiction transfer is a worrying and increasingly reported after-effect of bariatric surgery, as the loss of weight apparently does nothing to alleviate the addictive behaviour. Up to BO per cent of post surgical patients are reported to be transferring their addiction to other quarters (alcohol, gambling, promiscuous behaviour etc) to the point of self destruction. Addiction transfer appears to have a neurological basis, as research suggests that the same biochemical processes are at work in multiple types of impulse-control disorders. Each seems to trigger the same reward sites in the brain, resulting in cravings that are difficult to resist.

Weight loss with very low calorie diets has a clear advantage. When used strictly. ketogenic total food replacement diets are not perceived by the body as a deprivation condition requiring an alternative pleasurable stimulus which can lead to addiction transfer. Once in ‘ketosis’, a high percentage of patients report a mild euphoria or at least a sense of comfort and well being. VLCDs are rapidly being recognised as perhaps the only weight loss method that engenders the many health benefits of weight 1055 and crucially leaves the patient physically and psychologically healthy afterwards.

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FOR WANT OF A PLACEBO

…the strongest evidence for therapeutic interventions is provided by systematic review of randomized, double-blind, placebo-controlled trials involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, difficulties in ascertaining who is an expert, and more.

Wikipedia

Stephen Kreitman Ph.D. R.NJutr. (UK Registered Nutritionist) and Valerie Beeson Howard Foundation Research Ltd, Cambridge UK.

The Wikipedia quote above is one of countless examples that show the almost universal acceptance of this principle. There are, however, serious implications when the criteria for “evidence’ are defined in a manner that excludes other forms of valid evidence. A cliche catchphrase can become a cloak of invisibility. The idea of evidence based medicine would seem to be fairly uncontroversial, and indeed guides the actions of the UK healthcare community. After all, if there is no proof of efficacy, there is no justification for the use of a given treatment.

The classic randomised. double blind, placebo controlled trial is undoubtedly a powerful tool in the development of therapeutic treatments and procedures in the world of healthcare. The placebo effect is a well-known and unquestioned factor in the assessment of any potential treatment, andit is therefore logical to defer to any study that works to eliminate this effect. For this reason, all respected medical journals, most of the healthcare community, and certainly the government regulators require studies to meet these criteria before a treatment will even be considered.

Unfortunately, there are drawbacks. The most immediate difficulty with the classic notion of evidence based research is that some situations do not lend themselves well (or at all) to placebo controlled, double blind studies. In such cases, valuable information may be filtered out by the qualifiers set during literature searches and that information will never be seen by the very community that stands to benefit.

As a case in point, one of the more serious current healthcare problems is the rapid proliferation of type 2 diabetes. Current estimated costs to the NHS for treatment of this problem are a staggering E1 million per hour. However, a weight loss approach is available that costs the NHS nothing. can usually normalise blood sugars within a few days (even in long standing diabetes) and in most cases actually put type 2 diabetes into remission. This important clinical knowledge is virtually unknown because in this instance, it is impossible to design a placebo controlled study. Even thorough research of existing literature will be futile, since the information will usually be filtered out and not available for consideration.

Type 2 diabetes is usually a consequence of excess weight and it has been recognised for decades that weight loss will improve the clinical condition. In recent years, bariatric surgeons have become bolder with their own assertions and many now claim to ‘cure’ diabetes or at least put the disease into remission. It is certainly true that the weight loss associated with bariatric surgery can indeed put diabetes into remission, but the secondary claim – that surgery is the only means of accomplishing this – cannot be supported. If however, evidence of alternative means of substantial weight loss are filtered out and never even considered. bariatric surgery (by default) becomes the method of choice.

Shifting the balance of evidence

While case studies are often considered to be a lesser level of evidence, the balance of believable evidence must shift, especially when the number of cases being audited becomes virtually the entire treatment population. For the past 25 years GPs and pharmacists have been treating overweight and obese patients with very low calorie diets and monitoringtheir progress weekly over the course of their treatment. Those medical details and weekly progress reports have all been recorded, and a number of audits from individual GP practices and a 25 practice meta-audit have been published. As it is impossible to provide a placebo control for a VLCD, these results have been Largely unrecognised.

As the population of GP practices and pharmacies managing weight with VLCD has expanded and computer records become more available, it has become theoretically possible to audit the entire population. An audit from a group of pharmacies in the Republic of Ireland has provided data for over 9,000 Lipotrim patients. A single pharmacy in Prestwich. Manchester has provided audit data for over 1.100 dieting patients. Since these patients are seen weekly and their progress recorded by the health professionals, the information should be viewed as highly credible. The weight losses are having the same effect on type 2 diabetes as that reported for surgery. Patients, therefore, are not permitted to start the diet unless the GP has stopped diabetic medication. Blood sugars will normalise within a few days, and with a few weeks weight loss it is unlikely that any further diabetic medication will be required as long as they maintain some of the weight loss.

The key to the safety and efficacy of weight loss with VLCDs is the knowledgeable screening and continued monitoring by well trained health professionals. The extension of the medical programme as a pharmacy service has proven invaluable since pharmacy offers many advantages over GP treatment for a substantial number of reasons, not the least of which are accessibility and the availability for continued support long after the weight is lost.

The benefits of weight loss

NICE guidelines acknowledge extended use of VLCDs when properly monitored by healthcare professionals. There is certainly plenty of justification for helping overweight patients: weight loss can Lower blood pressure. normalise blood lipids, practically eliminate type 2 diabetes, reduce the severity of asthma, bring relief to arthritics, increase fertility, relieve sleep apnoea, provide an opportunity for patients to be considered for elective surgery, decrease the need for antidepressants, make exercise more possible – thus improving cardiovascular health and vastly improve the quality of life for patients.

There is now a 30 year history of safe and effective worldwide usage of total food replacements based upon the concept of low fat nutrient-complete enteral feeds (VLCDs as they came to be known). An enormous volume of scientific and medical literature has been thoroughly evaluated by expert committees and they have been recognised as safe and, in cases such as type 2 diabetes, more effective than standard weight loss methods. An expanding network of health professionals in UK and Irish pharmacies are now offering a range of treatments for weight problems. They have the training, the respect of the public, the contact hours and the desire to offer weight management as an expanded professional service. NICE recommends that specialists be used: these trained and experienced pharmacists and GPs are achieving considerable success and their success should not remain invisible for want of a suitable placebo.

“The current burden of morbid obesity in the UK is approximately 720,000 patients who meet NICE criteria for eligibility for surgery. Lost year, only 4,000 operations for morbid obesity were performed in the public and private sector combined.”‘

Even if the number of patients being treated by surgery was doubled, the impact on the problem would still be small. Doubling the costs of the surgery and aftercare would raise the percentage from a paltry 0.5 per cent to a marginally Less paltry 1.1 per cent_ This is still far short of the treatment needs of the seriously overweight population. Most surveys now estimate that 60 per cent of the UK population is overweight and about 30 per cent already obese. Assuming a total population of 60 million in the UK the number of people with a weight problem calculates to 36 million overweight and 18 million obese. In the audit from the Irish pharmacies mentioned earlier, 7,259 people lost more than 5 per cent of their prediet weight. 2.969 lost more than 10 per cent. In the Prestwich pharmacy, 94 per cent lost more than 5 per cent of their prediet vveight, 47 per cent lost more than 10 per cent and. 21 per cent of the patients lost more than 20 per cent.

Obviously, something more readily available than just surgery is needed, not only for treatment but also to prevent the progression from overweight to obesity to the massive obesity that passes the threshold for surgical intervention. Such methods are already available and would be more widely recognised if the usual search limits for evidence based treatments were modified to accept other perfectly valid forms of evidence. In

Reference

1. Thc Provision of Bariatric Surgery in the United Kingdom! Past, Present and Future Considerations: The Road to Excellence. Department of Bariatric Surgery, Imperial College Healthcare, Charing Cross Hospital, London, September, 2009.

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