Category Archives: NAPC REVIEW

WEIGHT GAIN LOSS OR MAINTENANCE – TRACKING THE CALORIE BALANCE POINT

S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist), & V. Beeson Howard Foundation Research Ltd. Cambridge UK

It is widely understood that weight loss, weight gain or weight maintenance is determined by the relationship between Calories eaten compared with Calories used. For each individual, with unique genetics and distinctive lifestyles, it makes sense that the Calorie balance point will differ between people – along with individual differences in almost every other aspect of life. Yet we are expected to take the values of 2000 Calories a day for women and 2500 Calories a day for men as fixed balance points and when reality proves different we are expected to censure the individual.

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The true energy balance level – the Calorie intake level that will provide for weight maintenance rather than gain or loss
for an individual, is a very important piece of information. Weight maintenance is the most difficult aspect of weight control and without an accurate determination of the critical equilibrium Calorie level, people must rely on guesswork. A successful outcome becomes very unlikely.

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Measuring the energy expended by people living normal lives is almost impossible. There are techniques using double isotope labelledwater, which are extremely expensive and virtually never used. Fortunately, whatever the energy levels used by individuals, they are surprisingly consistent. The reason for this is that despite the unrealistic claims for a massive Calorie usage with exercise equipment, the reality is much more depressing. A mile run uses about 100 extra Calories, not far from the contribution provided by a sports drink. Using up a pound of body fat, however, requires a deficit of 3500 calories. Few seriously overweight people have the capacity to run the 35 miles it takes to lose an extra
pound of fat weight. So, Calories used each day for most people are remarkably consistant. What about intake? Under most conditions it is extremely difficult to measure actual daily intake. There has been, however, an exciting benefit from the auditing of weight loss results with dieters using the Lipotrim pharmacy service. The vast majority of compliant dieters S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist), & V. Beeson Howard Foundation Research Ltd. Cambridge UK haveweight loss experiences that follow the pattern seen in the case shown here. Many pharmacies have hundreds of such cases. It should be obvious that the weight loss over a fixed time is virtually the same, week after week. This must mean that essentially the same amount of fat is being depleted every day, and since the Calories provided
by the Lipotrim diet formulas are constant, the calories the body must provide to make up the difference between the amount eaten and the amount used (defined as dieting) must be about the same every day

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The patient record keeping and audit tool, the Lipotrim Patient Tracker, used by many pharmacies running the service
has now been augmented to display the Calories used by each compliant dieter. Assessing the Calories used per day by
220 dieters treated by pharmacist, Gareth Evans, yielded on average 2171 Calories, however comparing the 187 females with the 33 males in the sample yielded an average Calorie usage of 2084 for women and 2666 for men. Quite realistic averages. The reality, however, for individuals can be considerably different from the group averages. The graph below shows the actual distribution of equilibrium Calories. Thirty one percent of the women had Calorie expenditures above 2000 and forty five percent had values below 2000 – some far below. These people will have vastly different maintenance experiences if they adhere to a 2000 Calorie a day maintenance regime. While there are fewer men in the sample, it is clear that there is a substantial spread in the individual values and about 33% of this cohort are below the 2500 classic value. There is yet another critically important consequence of identifying the equilibrium value for Calorie intake that determines whether there will be maintenance, gain or loss. There have been articles in the press in recent months suggesting that weight lossis trivially easy. The notion that cutting out a piece of toast a day (about 80 Calories) if
done every day will result in a loss of over 8 pounds in a year can not be valid because seriously overweight and obese people are not eating at the equilibrium intake. Yes it would be true for an individual with a personal maintenance level of 2000 Calories and who was consistently eating at that level to lose weight by cutting 80 Calories a day out of their daily intake. It is unrealistic to think that a seriously overweight person is habitually eating 2000 calories a day. Eating 80 calories less than the typical, 3000 Calories (pick a different excessive number if you don’t like 3000) will only slow the weight gain a bit. The application of the Patient Tracker software is advancing the understanding of weight loss and maintenance of real people and also documenting the substantial impact on the management of weight related medical problems such as type 2 diabetes and hypertension. It is also providing valuable data which is satisfying the need for evidence based treatment.

PDF version: 2-7-napc-calorie-balance-point

ADVANCED OBESITY MANAGEMENT TRAINING SOLUTIONS

S.N Kreitzman Ph.D. (Nutritional Biochemistry) R.Nutr. (UK Registered Nutritionist),
S. A. Kreitzman, & V. Beeson Howard Foundation Research Ltd. Cambridge UK

THE EFFECTIVENESS OF VERY LOW CALORIE DIETS IN MANAGING OBESITY
Obesity is a serious problem in modern society, and one that needs to be urgently addressed by healthcare professionals. Unfortunately, widespread obesity management will not be possible until healthcare professionals accept the brutal fact that advising an obese patient to ‘eat less” is as misguided as managing an alcoholic by advising him or her to “drink less.”
In the first instance, advanced obesity management must recognise that there is a difference between people who become .)ese and the rest of the normal weight j,opulation. Not every drinker becomes an alcoholic, and in the same way, only some people become obese. This is not a trivial comparison. Many people can and do control their eating behaviour arid 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 roblem
becomes clear.
The link between addiction and obesity is finally now being reflected 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 naltrexone in conjunction with bupropion as a weight loss treatment. It is important to recognise the basic fact that there is a component of addiction in food abuse and ultimately obesity. The most powerful long term treatment for addictions is complete abstinence from the addictive substance. A reformed smoker is someone who does not smoke, and a reformed alcoholic is someone who does not drink Comprehending this simple reality explains why total food replacement formula (very low calorie diets) are extremely effective and conventional low calorie diets are much less effective for seriously overweight patients. To treat any addiction (including obesity) effectively it is necessary to stop the substance of abuse. Very low calorie diets – essentially low fat enteral feeds – are absolutely necessary because they permit a patient to safely stop eating for prolonged periods. No lifestyle or behavioural change can be effective while the patient is caught in the biological quagmire of addiction. 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 or her life and remain healthy 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 replacementis the only means by which those who are subject to food abuse may avoid the addictive stimulus that perpetuates their weight problem.
EVIDENCED BASED CARE
The rapid proliferation of type 2 diabetes is currently one of the more serious healthcare problems. Current estimated costs to the NHS for treatment of this problem are a staggering El million per hour. In almost all cases however, a simple treatment exists that costs the NHS nothing, can 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 inadequately recognised because of the mantra for evidence based care. It is impossible to design a double blind placebo controlled study of VLCD.
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 VLCDs and monitoring their progress weekly over the course of their treatment. Those medical details and weekly progress reports have all been recorded over the years, and a number of audits from individual GP
practices and a 25 practice meta-audit have been published.
As the population of GP practices and pharmacies has expanded and computerised patient records have become more available, it has become Training to use VLCD properly requires education
Dieters can safely remove the addictive substance (food) and remain healthy theoretically possible to audit the entire population. A sample from a group of pharmacies in the Republic of Ireland has provided audit data for over 9000 Lipotrim patients. A single pharmacy in Prestwich, Manchester has provided audit data for over 1100 dieting Lipotrim patients. Since these patients are seen weekly and progress recorded by health professionals, the information should be viewed as highly credible and EVIDENCE BASED.
At Prestwich 1148 overweight patients with a median BMI of 33.6 kg/m’ were enrolled into the Lipotrim weight management programme. Of these, 25% were morbidly obese with a BMI >40 kg/ m2. At the time of audit, during which manypatients were still actively dieting, the median BMI had decreased to <30 kg/m2. 94% of the dieters lost more than 5% of their pre-diet weight, 47% lost more than 10% and 21% of the patients lost more than 20%. Importantly, all patients with type 2 diabetes had their medication stopped by their GP.’ The weight losses (comparable in most cases to that achieved by bariatric surgery) are having the same effect on type 2 diabetes as that reported for surgical procedures. The effect is in fact so dramatic, patients are not permitted to start the diet unless the GP has stopped diabetic medication. Blood sugars will normalize within a few days, and with afew weeks weight loss it is unlikely that any further diabetic medication will be required.
Training to use VLCD properly requires education. There are simply too many myths. The training programme for pharmacists running the Lipotrim weight management programme was awarded the SMART Best Educational Training Award For Pharmacists in 2002. Based upon sound physiological principles that most professionals know but are continuously seduced to ignore, there must be a greater recognition of need for VLCD, the only widely available tool for obese patients mired in the addiction aspect of food abuse. •
1. (Data presented at the 2010 National Obesity Forum Conference by Pharmacist Fin McCaul)

PDF version: 2-1NAPC advanced obesity management

OBESITY PANDEMIC – DIABETES DETERRENCE BY WEIGHT LOSS: PHARMACY BENEFITS PRIMARY CARE

It should be reasonable to justify practice time and resources to assist overweight and obese patients lose their weight. The link to type II diabetes alone is sufficient. With rapid weight loss, normalisation of blood sugar levels is achieved in days and with further weight loss, the disease can be held in remission. Better long term glycaemic control is achieved with rapid weight loss, even after some weight regain, than is achieved with the same weight lost more slowly. About 50% of hypertensive patients can reduce drug treatments with weight loss. Surgical interventions can be scheduled when substantial weight is lost. Fewer anti-depressants are required and overall, the frequency of GP visits is significantly
lower for leaner patients.

There is no shortage of choice to meet the weight loss needs of individual patients. Drugs, both current and promised for the future, dietetic referral, exercise on prescription, and pharmacy based treatment programmes are all needed in order to deal with the massive problem of obesity. Each has a place depending upon the specific clinical needs of the patient. An exercise prescription may not be the best choice for a 40 stone patient who may struggle simply to walk, which at this weight is considerable exercise. Weight loss has been advocated as an adjunct to treatment for patients with
conditions such as diabetes type 2, hypertension, osteoarthritis and a catalogue of other disabilities. Generally, little attention is paid to this option because of the difficulty patients have experienced in losing adequate amounts of weight and keep it off. The widespread availability of effective weight loss programmes in UK and Irish pharmacies, however, argues strongly for offering overweight patients, especially type 2 diabetics, an opportunity to try a course that leads to less dependence on drugs and frequently leads to long term remission of disease.

For diabetes, there are really two basic facts to consider. The first is that type II diabetes is a disease that has a primary
etiology which is close to 100% REVERSIBLY related to excess body weight. The second fact is that diabetic patients can lose enough weight within a few days to bring their blood sugars under control and enough further weight within weeks to
crucially reduce cardiovascular risk factors and apparently keep the disease in remission, even with some weight regain.

WEIGHT SPIRAL:

Standard treatment for type 2 diabetes, with emphasis on using drugs to lower the blood sugar levels, often results in a
relentless vicious circle. High blood sugar leads to drug intervention, which results in increased body weight, which in turn elevates the blood sugar, which increases the requirement for more potent drugs, which spirals to obesity and possible insulin dependency. Patients are getting fatter as a result of treatment and this necessitates more aggressive drug usage. With significant weight loss, drug usage can be reduced and in many cases stopped permanently.

LONG TERM WEIGHT MANAGEMENT

While willpower can often help people lose weight over a short defined period, control for the months, years or even
decades required for stability is quite a different story. Loss of weight by any means confers absolutely no lasting legacy for weight maintenance. Weight loss, however achieved, is only the beginning of the treatment, not the end point. When the drug therapy is discontinued.
When the counsellor moves on. When the patient is “cured” of excess weight. This is the point at which a dieter requires the maximum attention and assistance. Weight management requires control of eating behaviour over a sustained period of time and the implementation of lifestyle changes. Justifying practice time and resources for a patient who has achieved weight loss and is now both healthier and at a normal weight is difficult. The expectation that this patient will sustain the weight loss without considerable help, however, is naïve. Pharmacy based programmes are ideal for the varying long term weight management needs of patients.

Obesity prevention can also be part of the pharmacy contribution to health promotion services; dealing with excess weight before it reaches obese levels and exacerbates comorbidities. The care of patients during weight loss, is advantageous when monitored by a pharmacist, who understands the implications of other drug treatments that may interact with the weight loss programme.
But it is at the post diet stage that the pharmacist is best equipped to provide essential long range guidance, support and education that will increase the length of time that the weight loss is maintained.
Both the new GP and the pharmacy contracts strongly encourage interactive efforts to deal with a range of health problems, most of which have weight related implications. Weight loss is vital for management of, cholesterol,
blood lipids, diabetes, hypertension or asthma. It even impacts programmes for smoking cessation.

ACHIEVING A MAXIMUM SAFE RATE OF WEIGHT LOSS

Modest reductions in Calories can theoretically result in weight loss. Of course, the modest reduction has to be from the
equilibrium level, not from current intake. If a person is overeating by 2000 Calories a day (very common in the obese), a modest reduction in Calorie intake will not cause weight loss.
There is a maximum rate of weight loss for any individual. A total fast provides zero calories and therefore requires that all the Calories necessary for life come from the body fuel reserves. A total fast, however, provides no nutrients and since an obese patient has a far greater reserve of calories than stores of other essential nutrients, a total fast is out of the question as a treatment.
To be healthy, a diet has to supply adequate essential amino acids, essential fatty acids, vitamins, minerals and trace
elements. A total fast cannot be a valid treatment for obesity. The simple idea of reducing fat levels in an enteral formula
solves both the Calorie and the nutrient problem. An ideal nutritional product with the absolute minimum of Calories consistent with a healthy diet is achieved. Lipotrim is an example of such a product, providing a maximum safe rate of weight loss. The literature on safety and efficacy is massive. The time has really come to pay attention to it.

BENEFITS OF WEIGHT LOSS

There is also an extensive literature on the beneficial effects of weight loss on cardiovascular risk factors, on
blood lipid profiles and blood pressure. Managing weight in general practice is time consuming. The beneficial results from reliable weight loss on the glycaemic control and the cardiovascular risk factors more than justifies pharmacy cooperation. It benefits patients and makes good use of pharmacists’ training and facilities.
Weight is extremely important to patients generally and has a critical influence on the clinical course of many medical conditions. Uniquely, however, with type II diabetes, because the blood sugar can normalize so quickly under conditions of rapid weight loss, it is essential that hypoglycaemic medications are stopped prior to dieting. This requires an understanding, on the part of the prescribing GP, of the need to stop drug treatment and follow up of the patients.

THE IMPORTANCE OF PHARMACY IN WEIGHT MANAGEMENT

The need to deal with excess weight is no longer simply a cosmetic issue. Obesity has become pandemic. The serious consequences of excess weight are being acknowledged as type 2 diabetes rates soar in children as well as adults. There is
probably no other service that a pharmacist can provide that will prove to be as valuable to the needs of general practice as weight management. When effective self-funding programmes are available that do not require allocation of scarce resources from PCTs, it is hard to imagine any pharmacy failing to cooperate with a weight management programme. The problem has become so pervasive, that it will take a wide variety of treatments, drugs and public education to have any impact. Hospital programmes for weight management are overwhelmed. Pharmacy is the best community resource
and pharmacists’ training ideal for providing professional assistance in dealing with the major health issue of the decade.

REFERENCES

Wing RR, Blair E et al. Calorie restriction per se is a significant factor in improvement in glycemic control and insulin
sensitivity during weight loss in obese NIDDM patients. Diabetes Care 17:30- 36,1994.
Wing RR, Marcus M & Bononi P. Glycemic control after weight loss is affected by how weight loss is achieved. Diabetes, 39: suppl 1, 50A,1990.
Wing RR, Marcus MD, Salata R, Epstein LH, Miaskiewicz S & Blair EH. Effects of a very low calorie diet on long term glycemic control in obese type II diabetic subjects. Arch Int Med, 151: 1334-1340, 1991.
Weck M, Hanefeld M & Schollberg K. Effects of VLCD in obese NIDDM (noninsulin dependent diabetes) on glucose,
insulin and C peptide dynamics. Internat J Obes, 13: suppl 2, 159-160, 1989.
Uusitupa M, Alaakso M et al. Effects of a very-low-calorie-diet on metabolic control and cardiovascular risk factors in the treatment of obese non-insulindependent diabetes. Amer J Clin Nutr. 51:768-773,1990.
Shaper AG, Wannamethee SG & Walker M. Body weight: implications for the prevention of coronary heart disease, stroke and diabetes mellitus in a cohort study of middle aged men. Brit Med J, 314: 1311-1317, 1997.
Reports on tasks for scientific cooperation (EU SCOOP) Report of experts participating in Task 7.3, September 2002
Collection of data on products intended for use in very-low-caloriediets Directorate-General Health and Consumer Protectionz

PDF version: 2-6-obesity-pandemic

SUCCESSFUL WEIGHT MANAGEMENT IN PRIMARY CARE

Stephen Kreitzman Ph.D, (UK Registered Nutritionist) & Valerie Beeson
Howard Foundation Research Ltd. Cambridge

Weight loss goals are not utopian dreams. Diabetics off their drugs in days. Blood pressure reduced.
Patients qualifying for elective surgery. Depression tempered. Fertility enhanced. Patients capable of a more active lifestyle.
Blood lipid profiles improved. Self esteem and quality of life enhanced. These are goals achieved routinely by weight loss.
They are being achieved by your GP colleagues and by your pharmacist colleagues. And it isn’t necessary to wait for PCT funding.
Obesity management is basic science. People have to eat a lot fewer calories than they use. That is, they have to maintain a large calorie gap. Calories do count and the laws of physics can not be violated regardless of the macronutrient profile of the foods eaten.

EXERCISE

Obesity management also requires more than exercise at the levels realistically achievable by seriously overweight people. Obesity management requires an understanding of the full impact of extra ener-gy expenditure – even in the unlikely event that the extra expenditure is substantial – when energy intake continues to be excessive. Obese people have eaten and in all probability are still eating more calories than they need.
Their excess intake can often be measured in the many hundreds of calories. It takes a very large amount of exercise to cope with these excess food calories before any contribution can be made from the body’s fat stores and cause weight loss. After coping with the excess food calories, it takes an additional deficit of 3500 calories to consume a single pound of body fat. Often it takes a major effort for obese people simply to accomplish activities that other people take for granted. To expect obese people to dissipate very large numbers of excessive calories by exercise is naïve. To risk the heat overload generated by intensive exercise in people whose fat mass, a considerable and effective insulation material, dangerously impedes heat loss, is unwise.

WEIGHT MANAGEMENT IS ACHIEVABLE

Weight loss of significant magnitude, even in seriously obese patients, is achievable either in your own practice or with the assistance of a rapidly growing number of trained pharmacists. Pharmacists over the last 3 years are getting excellent
results running the same professional Lipotrim prot-ocols as have been run exclusively in UK general practices and hospital clinics since 1987. The parliamentary all party pharmacy group (APPG) has called for greater pharmacy
involvement in obesity management and pharmacists are responding to that call.

PHYSIOLOGY

There are some fundamental concepts of physiology that must be understood in order to treat weight problems successfully. The most frequently misunderstood concept, even by professionals, is the rela-tionship between weight loss and body fat loss. They are not the same. Weight loss can be achieved with a diuretic, by sweating and even by exercise, without any loss of body fat. The primary fuel providing energy for the body is glucose and it’s reserve polysaccharide, glycogen. These carbohydrates are stored in the body in the liver, muscles and fat cells. Fat people can store a considerable amount of glycogen in their numerous fat cells, in comparison with thin people who usually only store about a pound or two of this carbohydrate fuel. It is extremely important to recognize that the carbohydrate fuel is stored in a highly hydrated state – 3-5 parts water to each part of glycogen. This results in what amounts to a diuresis as glycogen is utilized. Instead of 3500 calories required per pound of fat weight lost, weight lost as glycogen and its associated water requires only about 360 Calories per pound, 10% of the energy deficit. Further, repletion of glycogen and water weight is rapid and necessary. Shifting glycogen and water weight on and off should not be confused with obesity management.

WEIGHT LOSS USING NUTRITIONAL REPLACEMENT THERAPY

Obesity management requires enough of a calorie deficit to deal with 7700 kcal per kg of fat weight lost. An individual of
average height has to lose about 3 kg of weight to reduce BMI by a single unit. Therefore a calorie deficit of energy use
compared with intake has to reach about 23,100 kcal in order to achieve one unit reduction in BMI. This can most
realistically be achieved by maximizing the calorie gap between intake and expenditure. The absolute maximum is obviously achieved by a total fast, however, a total fast provides no essential nutrients and would therefore lead to serious health problems and ultimately death. Energy intake is not required since each stone of excess weight is a store of over 37,000 kcal. Providing the essential nutrients of vitamins, minerals, trace elements, essential amino acids and fatty acids entails providing some calories, therefore the maximum safe caloric gap is defined by the calorie content of an intake providing all essential nutrients in adequate amounts. This is achieved, by a carefully designed formulation, in approximately 400 kcal per day. Nutritional replacement therapy formulations have a long history of safe and effective maintenance of patients for prolonged periods, however, they are ordinarily designed to provide enough energy for weight maintenance or even weight gain. Drastic elimination of fat calories from these formulations, however, can provide for essential nutrition while supporting sustained weight loss. This is the basis for the success of the Lipotrim obesity management system.

OVERCOMING “ADDICTIVE” EATING BEHAVIOUR TO ACHIEVE LIFESTYLE CHANGE

It is becoming increasingly apparent that excessive consumption of food shares many of the characteristics of addictive behaviours towards other substances of abuse.
Whether it be tobacco, alcohol or drugs, once excessive consumption is evident, the only way to have any reasonable chance of regaining control is to stop completely the substance being abused. While total abstinence is achievable and
generally recommended when dealing with these other substances, obese patients are usually encouraged to control their excesses by consciously overriding their drives to eat in the face of the temptations of continued exposure to food. The frequent failure to achieve this over a prolonged period is not surprising. What is required is a complete withdrawal from the lure of food for as long as possible. This is achievable using a nutritional replace-ment formulation, which is not generally perceived as food. When food avoidance is complete, it has the dramatic effect of re-establishing more cont-rolled behaviour towards food when traditional food is reintroduced. This positive benefit is commonly seen, for example, when people substitute skimmed milk for whole milk in tea or coffee. It is rare for these people to reintroduce whole milk again. Long term lifestyle change in eating behaviour becomes considerably more likely when there is a complete break from the substance of abuse. Patients adhering strictly to the Lipotrim total food replacement formulations have a vastly improved record of post diet weight control compared with historic approaches.

ADVANTAGES OF PHARMACY OVER IN-HOUSE TREATMENT

While many prac-tices prefer to manage their own obese patients with Lipotrim, there are practical limitations that often
make it desirable to utilize a pharmacy. In addition to the obvious considerations of time availability, where a pharmacist could treat a patient at almost any time during long opening hours, time available in the surgery is generally much more constrained. As a result, treatment is often restricted to the most severe cases where the weight has contributed to some co-morbid condition such as diabetes or when the patient faces a long delay in attaining surgical help unless weight is lost. With almost a quarter of the adult population now clinically obese and over half of the population overweight, the treatment burden can rapidly become overwhelming for the practice. Also, it is widely recognized that prevention by intervention before the patient becomes obese is preferable. Weight is not considered a medical problem below BMI30 and it is hard to justify practice time for lower weight patients who are otherwise still heal-thy. Similarly, once a patient has achieved weight loss and is at a normal weight, they are greatly in need of further, long term maintenance assistance, but this is difficult to justify in practice since they are now at a normal weight. There are, however, some medical conditions where either total management in practice or a shared management with the pharmacist is necessary. This is most dramatic with type II diabetes treated with oral agents. There is a p r e c i p i t o u s normalization of blood sugar, usually within the first 3-5 days of Lipotrim treatment. Continued use of the oral agents in the presence of normal sugars can become problematic and therefore medication needs to be stopped or severely reduced. This cannot be done by the pharmacist without the cooperation of the primary care doctor.

THE FACTS ARE IN THE LITERATURE

Obesity has finally become recognized as a major public health problem and the primary care team is being looked upon
to deal with it. The approach to obesity treatment briefly outlined in this short piece is extremely well documented in what has become a vast scientific and medical literature. Weight losses of about 1 stone per month for women and even
more for men are not only achievable, but are also expected. They are proven safe when used under knowledgeable
care and there is no longer any excuse for patients to endure futile attempts to manage their obesity. Considerable
discussion of the medical science can be found on the UK Food Education Society web site at www.foodedsoc.org.

PDF version: 2-5-successful

OBESITY PANDEMIC – DIABETES DETERRENCE BY WEIGHT LOSS: PHARMACY BENEFITS PRIMARY CARE

Stephen Kreitzman Ph.D, R.Nut. (UK Registered Nutritionist) & Valerie Beeson
Howard Foundation Research Ltd. Cambridge UK

It should be reasonable to justify practice time and resources to assist overweight and obese patients lose their weight. The link to type II diabetes alone is sufficient. With rapid weight loss, normalisation of blood sugar
levels is achieved in days and with further weight loss, the disease can be held in remission. Better long term glycaemic control is achieved with rapid weight loss, even after some weight regain, than is achieved with the same weight lost more slowly. About 50% of hypertensive patients can reduce drug treatments with weight
loss. Surgical interventions can be scheduled when substantial weight is lost. Fewer anti-depressants are required and overall, the frequency of GP visits is significantly lower for leaner patients.

There is no shortage of choice to meet the weight loss needs of individual patients. Drugs, both current and promised for the future, dietetic referral, exercise on prescription, and pharmacy based treatment programmes are all needed in order to deal with the massive problem of obesity. Each has a place depending upon the specific clinical needs of the patient. An exercise prescription may not be the best choice for a 40 stone patient who may struggle simply to walk, which at this weight is considerable exercise. Weight loss has been advocated as an adjunct to treatment for patients with conditions such as diabetes type 2, hypertension,
osteoarthritis and a catalogue of other disabilities. Generally, little attention is paid to this option because of the difficulty patients have experienced in losing adequate amounts of weight and keep it off. The widespread availability of effective weight loss programmes in UK and Irish pharmacies, however, argues strongly for offering overweight patients, especially type 2 diabetics, an opportunity to try a course that leads to less dependence on drugs and frequently leads to long term remission of disease.

Diabetes type ll is nearly 100% reversibly related to excess weight

For diabetes, there are really two basic facts to consider. The first is that type II diabetes is a disease that has a primary etiology which is close to 100% REVERSIBLY related to excess body weight. The second fact is that diabetic patients can lose enough weight within a few days to bring their blood sugars under control and enough further weight within weeks to crucially reduce cardiovascular risk factors and apparently keep the disease in remission, even with some weight regain.

WEIGHT SPIRAL:

Standard treatment for type 2 diabetes, with emphasis on using drugs to lower the blood sugar levels, often results in a relentless vicious circle. High blood sugar leads to drug intervention, which results in increased body weight, which in turn elevates the blood sugar, which increases the requirement for more potent drugs,
which spirals to obesity and possible insulin dependency. Patients are getting fatter as a result of treatment and this necessitates more aggressive rug usage. With significant weight loss, drug usage can be reduced and in many cases stopped permanently.

LONG TERM WEIGHT MANAGEMENT

While willpower can often help people lose weight over a short defined period, control for the months, years or even decades required for stability is quite a different story. Loss of weight by any means confers absolutely no
lasting legacy for weight maintenance. Weight loss, however achieved, is only the beginning of the treatment, not the end point. When the drug therapy is discontinued. When the counsellor moves on. When the patient is “cured” of excess weight. This is the point at which a dieter requires the maximum attention and assistance.
Weight management requires control of eating behaviour over a sustained period of time and the implementation of lifestyle changes. Justifying practice time and resources for a patient who has achieved weight loss and is now both healthier and at a normal weight is difficult. The expectation that this patient will sustain the weight loss without considerable help, however, is naïve. Pharmacy based programmes are ideal for the varying long term weight management needs of patients.

Obesity prevention can also be part of the pharmacy contribution to health promotion services; dealing with excess weight before it reaches obese levels and exacerbates comorbidities. The care of patients during
weight loss, is advantageous when monitored by a pharmacist, who understands the implications of other drug
treatments that may interact with the weight loss programme. But it is at the post diet stage that the pharmacist
is best equipped to provide essential long range guidance, support and education that will increase the
length of time that the weight loss is maintained.
Both the new GP and the pharmacy contracts strongly encourage interactive efforts to deal with a range of health problems, most of which have weight related implications. Weight loss is vital for management of, cholesterol, blood lipids, diabetes, hypertension or asthma. It even impacts programmes for smoking cessation.

ACHIEVING A MAXIMUM SAFE RATE OF WEIGHT LOSS

Modest reductions in Calories can theoretically result in weight loss. Of course, the modest reduction has to be from the equilibrium level, not from current intake. If a person is overeating by 2000 Calories a day (very common in the obese), a modest reduction in Calorie intake will not cause weight loss.
There is a maximum rate of weight loss for any individual. A total fast provides zero calories and therefore requires that all the Calories necessary for life come from the body fuel reserves. A total fast, however, provides no nutrients and since an obese patient has a far greater reserve of calories than stores of other essential nutrients, a total fast is out of the question as a treatment. To be healthy, a diet has to supply
adequate essential amino acids, essential fatty acids, vitamins, minerals and trace elements. A total fast cannot be a valid treatment for obesity. The simple idea of reducing fat levels in an enteral formula solves both the Calorie and the nutrient problem. An ideal nutritional product with the absolute minimum of Calories consistent with a healthy diet is achieved. Lipotrim is an example of such a product, providing a maximum safe rate of weight loss. The literature on safety and efficacy is massive. The time has really come to pay attention to it.

BENEFITS OF WEIGHT LOSS

There is also an extensive literature on the beneficial effects of weight loss on cardiovascular risk factors, on blood lipid profiles and blood pressure. Managing weight in general practice is time consuming. The beneficial results from reliable weight loss on the glycaemic control and the cardiovascular risk factors more than justifies pharmacy cooperation. It benefits patients and makes good use of pharmacists’ training and facilities.
Weight is extremely important to patients generally and has a critical influence on the clinical course of many medical conditions. Uniquely, however, with type II diabetes, because the blood sugar can normalize so quickly under conditions of rapid weight loss, it is essential that hypoglycaemic medications are stopped prior to dieting. This requires an understanding, on the part of the prescribing GP, of the need to stop drug treatment and follow up of the patients.

THE IMPORTANCE OF PHARMACY IN WEIGHT MANAGEMENT

The need to deal with excess weight is no longer simply a cosmetic issue. Obesity has become pandemic. The serious consequences of excess weight are being acknowledged as type 2 diabetes rates soar in children as well as adults. There is probably no other service that a pharmacist can provide that will prove to be as valuable to the needs of general practice as weight management. When effective self-funding programmes are available that do not require allocation of scarce resources from PCTs, it is hard to imagine any pharmacy failing to cooperate with a weight management programme. The problem has become so pervasive, that it will take a wide variety of treatments, drugs and public education to have any impact. Hospital programmes for weight management are overwhelmed. Pharmacy is the best community resource and pharmacists’ training ideal for providing professional assistance in dealing with the major health issue of the decade.

REFERENCES

Wing RR, Blair E et al. Calorie restriction per se is a significant factor in improvement in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients. Diabetes Care 17:30-36,1994.
Wing RR, Marcus M & Bononi P. Glycemic control after weight loss is affected by how weight loss is achieved. Diabetes, 39: suppl 1, 50A,1990.
Wing RR, Marcus MD, Salata R, Epstein LH, Miaskiewicz S & Blair EH. Effects of a very low calorie diet on long term glycemic control in obese type II diabetic subjects. Arch Int Med, 151: 1334-1340, 1991.
Weck M, Hanefeld M & Schollberg K. Effects of VLCD in obese NIDDM (noninsulin dependent diabetes) on glucose, insulin and C peptide dynamics. Internat J Obes, 13: suppl 2, 159-160, 1989.
Uusitupa M, Alaakso M et al. Effects of a very-low-calorie-diet on metabolic control and cardiovascular risk factors in the treatment of obese non-insulindependent diabetes. Amer J Clin Nutr. 51:768-773,1990.
Shaper AG, Wannamethee SG & Walker M. Body weight: implications for the prevention of coronary heart disease, stroke and diabetes mellitus in a cohort study of middle aged men. Brit Med J, 314: 1311-1317, 1997.
Reports on tasks for scientific cooperation (EU SCOOP)
Report of experts participating in Task 7.3, September 2002 Collection of data on products intended for use in very-low-caloriediets Directorate-General Health and Consumer Protectionz

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SUCCEEDING WITH YOUR DIET – YOU HAD BETTER STOP

S.N Kreitzman Ph.D. R.Nutr. (UK Registered Nutritionist), S. A. Kreitzman, & V. Beeson,
Howard Foundation Research Ltd. Cambridge UK
The treatment of overweight and obese patients by healthcare professionals is increasingly being recognised as necessary. Unfortunately, the treatment options available have become more and more limited due to serious side effects or lack of sufficient efficacy. Currently in the UK, the major weight loss tools available are essentially limited to either a single drug or invasive surgery (with high morbidity and mortality rates).
In recent years, UK and Irish Pharmacists have been implementing strictly monitored Very Low Calorie Diet protocols, and have demonstrated that non-invasive weight management can be a viable option for healthcare professionals. It is however ironic that the appropriate medical management of obese patients could be potentially disrupted by an arbitrary limitation of use, which interferes with treatment and ultimately restricts the potential medical benefit of the weight loss effort.
It is worth taking a moment to look at some numbers in context.
Obese people (defined generally as those with a BMI above 30) have excess weights greater than 3 stone (roughly 20kg). In examining audit data from 1148 people being treated with Lipotrim at the Prestwich Pharmacy in Manchester, they presented with an average (mean) BMI of 35 and median BMI of 34. Therefore 574 of the 1148 started with a BMI in excess of 34. Ten percent began their diet with morbidly obese BMI’s of greater than 46 and 5% with a BMI over 50. In a separate audit of a further 9071 Lipotrim dieters from pharmacies in the Republic of Ireland, the mean starting BMI was 33 and more than half were over BMI 32. However 10% (more than 900 people) presented to the pharmacy for weight loss at BMI over 41 and over 450 people presented with a BMI in excess of 44. Unfortunately, many patients presenting to GPs have even larger weight problems, almost universally complicated by weight co-morbidities.
Limiting the time allocated for effective treatment is ill advised, just as it would be to withdraw antibiotics before a course is complete. Yet the rhetoric for ending VLCD treatment prematurely has become ritualized, and is often proclaimed without the recognition that it has no
basis whatsoever.
This piece of dietary Urban Legend has its origins over 30 years ago, when an over-zealous company marketed a product which claimed to be a commercial version of Dr George Blackburn’s highly successful ‘Protein Sparing Modified Fast’. Dr. Blackburn’s programme – essentially a home version of a low calorie enteral feed – was based upon a high-quality protein source (generally beef) supplemented with an intelligently constructed micronutrient collection of vitamin and mineral formulations. The commercial product exploiting his work was dubbed the ‘Liquid Protein Diet’ and promoted in 1976 by a book called The Last Chance Diet. Unfortunately, for many people it proved to be exactly that, as there were many deaths. The Liquid Protein product was an ill-conceived concoction of hydrolyzed cow hide and cherry syrup. It was nutritionally deadly. Banned in the late 1970s, such products bear no relationship to the modern nutrient complete low calorie enteral feeds (now generally called VLCD). Modern VLCD have more than 30 years of documented safe and effective use, and comparing them with the Liquid Protein experience is spurious.
When the protein sparing modified fast concept was extended (using proper scientific expertise) into a variety of commercial VLCD products an attemptwas made by one particular company in 1980 to sell it as a mail order product. With the memory of the Liquid Protein disaster still fresh in the public consciousness, the US Postal authorities refused to carry the VLCD unless the retailer agreed to recommend that its use be limited to a period of four weeks. Their logic, not unreasonable for the knowledge at the time, was that even a total fast was perfectly safe for up to 4 weeks. None of the victims of the Liquid Protein experience had problems in less than 8 weeks.
Following more than a decade of worldwide medical study involving several commercial VLCD, one large hospital based programme, limited the programme to 12 weeks of continuous VLCD treatment and used the experience to publish a considerable number of research papers, using data derived from these patients. The 12 week decision was totally arbitrary and there was never any suggestion that harm would have followed from extending the treatment. Protocols from other medical programmes were not constrained. Under the care of health professionals, who recognise that the hazards from weight loss treatment are only related to the impact on existing disease treatments, such as diabetes or hypertension, VLCD can be safe for as long as required, if BMI does not go below the normal range. Weight loss with VLCD in diabetics requires cessation of medication prior to dieting as the diet will normalise blood sugar in days. Weight
loss for people on hypotensive medication requires professional attention, since more than 50% of hypertension is weight related and the treatment must be altered in line with the BP reduction. Weight loss can alter the absorption rate of many drugs and those with a narrow safety spectrum must be monitored carefully. In healthy people, VLCD induced weight loss is benign.
Because of their research papers, and because the product in question became a brand leader, the “12 week” policy adopted in the hospital trials quickly became a common guideline.
The wisdom of interrupting treatment was rarely questioned by committees such as Codex or NICE; they simply accepted it as reasonable. There are many reasons, however, why such an arbitrary recommendation is not wise.
Firstly (and probably least important) is the well documented observation that once interrupted, VLCD is surprisingly difficult to restart. Virtually all of the metabolic adaptations that allow the body to use fat as a fuel (rather than glucose) occur at the start of dieting and ‘dietus interruptus’ is perhaps the most metabolically stressful.
The most important reason, however, can be understood from the audit statistics presented earlier. Twelve weeks is not enough diet time for any obese person’s treatment.
Consider: The average woman is said to be using about 2000 kcal per day. (It can be argued that as she gets heavier and movement becomes more difficult, even this number might be excessive). If no calories at all were eaten by the dieter, the calorie deficit would obviously be 2000 calories per day. To support life, body stores (eventually of fat) would have to provide all of the calories. Obviously, this creates the fastest possible scenario for the utilization of stored fat.
Each pound of fat tissue provides 3500 kcal. Therefore, the maximum weight loss, fasting totally, would be around 1/2 pound per day. In 12 weeks, no more than about 42 pounds of fat can be utilized. This weight loss is insufficient. It would leave the vast majority of obese dieters far short of the achievement of normal weight. Where co-morbidities are being treated by weight loss, there would be a high likelihood of treatment failure.
There is no justification for healthcare professionals who use an effective, noninvasive, dietary treatment for weight management to limit that treatment to some arbitrary time. No evidence for harm exists to warrant terminating treatment, and there is considerable evidence to justify the completion of the treatment. It is time for excathedra comments to be justified with evidence or silenced. •

PDF version: 2-3 NAPC REVIEW 2010 12 WEEKS

ACHIEVING WEIGHT MAINTENANCE AFTER SUBSTANTIAL VLCD WEIGHT LOSS

DIABETES ACHIEVING WEIGHT MAINTENANCE

AFTER SUBSTANTIAL VLCD WEIGHT LOSS

S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist),V. Beeson & S.A Kreitzman Howard Foundation Research Ltd. Cambridge UK

WEIGHT MAINTENANCE AFTER WEIGHT loss is perfectly possible, but not often achieved by traditional hypoenergetic diet programmes. Considering the paucity of evidence to support the idea that there is maintenance benefit from a slow rate of weight loss and the considerable amount of contrary evidence, it is very surprising that this idea persists.There is now recognition that even bariatric surgery suffers from unexpectedly high rates of recidivism after initial weight losses; this should have already altered the widespread expectation that weight maintenance should necessarily follow successful weight loss.We have reached a stage where VLCD and bariatric surgery are available to produce sufficient weight losses to promote medical benefits.At the top of the extensive list of co-morbidities associated with excess weight is type 2 diabetes. In order for these medical benefits to be sustained as long as possible, rapid weight loss and a structured, effective, maintenance programme are vitally important.
Weight regain after dieting can result from a variety of causes.The simplest of these is also the most common.The physiological principle here is that early weight losses are almost entirely due to the utilization of sugar and glycogen.These carbohydrate fuels with their associated bound water are regained quickly after restoration of normal eating, There is only a minimal actual change in fat storage — only small amounts of fat weight are lost, even when there may be a reasonable amount of weight loss due to depletion of the stored glycogen and its associated water. Lack of attention to an appropriate, structured, re- feeding can lead to carbo-loading, in a manner similar to the effect sought by endurance athletes.The consequence to a dieter; however is an excessive repletion of glycogen with its substantial rebound hydration.This can often produce weight regain in excess of the weight lost, and is a common feature after intermit-tent calorie restriction.
With a correct refeeding strategy, weight maintenance is much more assured.’Carbo loading’ requires depletion of glycogen followed by intake of high glycaemic index carbohydrate foods. Athletes often consume pasta, but fruit, bread, cereals etc. are just as effective.The result is a rapid overload of stored glycogen, often more than twice the pre-depletion levels.When the additional glycogen becomes bound to water for storage, considerable weight gain can be achieved.This is not a problem for an endurance athlete who will soon utilize the extra glycogen, but a considerable blow to a dieter who has just sustained prolonged food restriction in an attempt to lose weight.
Evidence for weight stability during a week of properly structured refeeding is demonstrated from an audit of patients attending a pharmacy based programme.

Before After
Refeeding Refeeding
Valid cases 146 146
Mean BMI 27.45 27.39
Median BMI 26.63 26.57

While there are indeed some minor variations in individual stability of BMI following the re-introduction of normal foods and re-establishing normal glycogen stores, these differences are usually trivial.

“New NHS research has revealed the shocking toll of preventable deaths caused by just one medical condition — diabetes — which is causing 24,000 needless deaths a year in England alone. It’s not just the old and middle-aged who are at riskYoung women with diabetes are 6 to 9 times more likely to die than their age group overall. And many more young people who don’t die will develop life threatening diseases later due to failure to manage their blood sugar. Badly controlled diabetes can lead to kidney disease, heart conditions, or blindness. It’s also the cause of 5,000 amputations a year mainly of legs or feet.With around 3 million diagnosed sufferers known to the health service, diabetes is said to be costing the NHS £9 billion a year about a tenth of the total health budget.”
File on Four. BBC Radio 4, 21 February 2012

Fig. I Design:Studies were required to I) have been conducted in the United States, 2) have included participants in a structured weight-loss program, 3) have provided follow-up data with variables estimates for y. Primary outcome variables were weight-loss maintenance in kilograms, weight-loss maintenance as a percentage of initial weight loss, and weight loss as percentage of initial body weight (reduced weight).
Weight Maintenance after Dieting

Weight loss with VLCD is especially beneficial for minimizing recidivism after substantial weight loss
Weight recidivism, when substantial weight loss has been achieved, can represent a more fundamental physiological problem. It is becoming increasingly accepted that food can become a substance of abuse, and that it shares the pathways common to addictions associated with tobacco, alcohol and drugs. It is an extremely rare occurrence when addicts are able to slowly wean themselves from the abused substance. Stopping the substance of abuse is the most effective strategy for almost all addictions, but there are serious consequences associated with a total cessation of food intake. In cases where the weight problem has become substantial enough that addictive mechanisms are likely, a case may be made that very low calorie formula diets (VLCD) are the only weight loss method with any real chance of succeeding, especially into the critical post-diet period.With a nutrient complete formula replacing all traditional foods, there is interference with the addictive processes and the dieter has a greatly improved chance for successful weight maintenance. Evidence that VLCD confers bet-ter long term weight maintenance than traditional hypoenergetic balanced diets has been repeatedly published.A particularly careful assessment was published in the American Journal of Clinical Nutrition in 2001 by James Anderson and co-workers.The report “Long-term weight-loss maintenance:a meta- analysis of US studies” compared 5 year post diet maintenance from published structured weight loss programmes. As can be seen from figure I . above, from 29 published studies that met the inclusion criteria, there was considerably more weight lost by the VLCD

Fig. 2 Many pharmacies in the UK using the Lipotrim PatientTracker software also track weight maintenance after completion of the weight loss programme. Results from Pharmacist Gareth Evans, for example, emphasize that post diet changes in BMI are minimal for the vast majority of dieters.

studies. After 5 years, the VLCD subjects still sustained a greater weight loss than the initial loss from the hypocaloric balanced diet.The criteria are described in the study design.
Maintenance of the weight lost is particularly important when treating a patient with type 2 diabetes.With the combination of rapid weight loss and a reliable maintenance opportunity,
VLCD are a vitally important option for the management of diabetes.
GPs already know the extent of the problem. Diabetes in particular, fuelled by an epidemic of overweight and obesity, is undermining the nation’s health. But it has been shown that with the aid of a very low calorie formula diet (VLCD), rapid weight loss leads to rapid remission of type 2 diabetes. A one-year study showed that BMI of obese diabetic patients was reduced by 5kg/m2 and that patients were able to discontinue insulin and oral hypoglycaemic agents for the whole year.2 A five-year follow-up study confirmed that VLCD treatment was safe and effective in overweight diabetic subjects. It has also been shown that normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes is achieved byVLCD dietary energy restriction.

 

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