Category Archives: NURSING IN PRACTICE

SHARING WEIGHT MANAGEMENT ADVICE WITH PATIENTS

We all know that the key to weight loss is eating less and exercising more. However, dropping to under 1,200 calories without supplementation leads to nutrient deficiencies, which perpetuates the myth that lower calorie diets are dangerous

It is comforting to know that nurses are one of the few groups left who understand the suffering experienced by patients who are overweight and who recognise obesity as a problem worthy of effective action. Weight control is difficult and unfortunately it is much easier to eat calories than it is to exercise them away. A calorie gap of 3,500 calories between the calories eaten and those used is necessary to dispose of a single pound of excess body fat – 3,500 calories represent
a substantial amount of exercise. If the calories actually eaten are more than the calories used by the other activities of the day, the exercise will only reduce the calorie excess and not result in weight loss. It might, however, slow the weight gain. It really is necessary to eat less in order to manage weight.

No easy solution

There is no secret to weight management: the calories eaten have to be considerably less than those being used for a sustained period of time. The continued health of the patient requires them to consume all the essential nutrients necessary for life and health, which becomes increasingly difficult as the amount of food consumed is reduced or treatments actively promote malabsorption.
If we maintain a varied selection of foods, we can feel reasonably confident that we are getting the complete array of essential nutrients. However, while the plants and animals we choose for food each have some of the essential nutrients required by man, none has them all. To get the right amounts for sustained health from unsupplemented foods it is absolutely essential that we eat in excess of 1,200 calories. Eating foods with lower calorie totals cannot provide all the nutrients that we need. The myth that dropping calories below about 1,200 in order to lose weight is unhealthy is true, but not because the calories are low – a fat person has an enormous store of calories available. The problem is that dieters become nutrient deficient.
Providing 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. Fuels available for the body are glucose (stored 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. He just needs to get the essential nutrients. When these come from a nutrient-complete formula food, the results are ideal: complete nourishment and minimal calories. Supplying the essential nutrients in a prepared mixture, such as in an enteral feed, assures that nutrient deficiencies do not occur.

The role of the pharmacist

An expanding network of pharmacists is 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 a professional service. NICE recommends that specialists be used for extended very low calorie diets (VLCDs).1 These pharmacists are trained and experienced specialists in the use of VLCD.
Pharmacies following this route are achieving a great deal and GPs and nurses are becoming much more comfortable directing overweight patients to these highly trained and experienced pharmacists. At the same time the availability of trained pharmacists is becoming more widespread, which is making these experts much more accessible to a wider deserving population.

Conclusion

Weight loss is more than a cosmetic issue. Weight loss can lower blood pressure, normalise blood lipids, practically
eliminate type 2 diabetes, reduce the severity of asthma, bring relief to arthritics, increase the fertility of women, relieve sleep apnoea, provide an opportunity for patients to be considered for elective surgery, decrease the need for antidepressants, make exercise more possible and thus improve cardiovascular health, and vastly improve the quality of life for patients in a prejudiced and intolerant world. Pharmacists are emerging as the weight management specialists, providing lifestyle advice, effective treatments and support, as well as follow-on help for the most difficult aspect of managing weight: the longterm maintenance of weight lost. Your overweight patients will appreciate knowing about it.

PDF version: 4-3-sharing-advice

TREATING OVERWEIGHT PATIENTS: WHAT ARE THE OPTIONS?

People suffer terribly from the consequences of their excess weight and many expect help from the health service. Here are some options…

A 5’2 woman who weighs 100 kg (15 st 10) has a BMI of 40 and is morbidly obese. If she manages to lose 5% of her weight, she will weigh 95 kg (14 st 13), which is a BMI of 38.6. Can anyone honestly say that this has been a sufficient treatment? To get her down in weight to the top of the normal range (BMI 25) she will have to lose 38.5 kg (approximately 6 stone).

Tell her to exercise?

The calories used in exercise will make a difference only if the patient is in calorie balance. Most overweight people are routinely eating in excess of their daily needs. Around 2,000 calories can be consumed with very little recognition that the average daily expenditure has been matched. Assuming, however unlikely, that calorie balance has been achieved, the excess weight represents 296,400 calories below the calorie balance level that will have to be used up by increased activity. At 100 calories for a mile run, the patient will simply have to run 3,000 miles (without any additional overeating).

Cut back a little to lose weight slowly?

Modest reductions in calories could theoretically result in weight loss, although the best efforts of the Swedish healthcare system could not produce any.1,2 Of course, it can’t be emphasised often enough, the modest reduction has to be from the equilibrium level, not from current intake. Standard advice has been to limit the rate of weight loss by encouraging a small calorie gap. This most often assures failure to lose substantial weight. Arguing that slow weight loss somehow results in better weight maintenance (except perhaps maintenance of the prediet weight) was convincingly demonstrated
to be false as far back as 1959. Stunkard showed that regardless of the programme for weight loss, or the expertise of the clinic, after one year 95% had put back all the lost weight.3 After two years 98% and by five years virtually all of the dieters had put the weight back on.

Faster weight loss is actually better

Very low calorie diet (VLCD) treatment has a well-documented, vastly better, record for weight loss and weight maintenance.4 The fallacy that reducing calorie intake sufficiently low to encourage a rapid loss of weight was harmful, resulted from the fact that the poor distribution of essential nutrients in ordinary foods makes it very difficult to create a nutrient-complete diet under conditions of food restriction. It is actually impossible to achieve an unsupplemented nutrient complete diet at intakes below 1,200 calories. When traditional food diets were attempted below 1,000 calories, dieters were put at risk. When the need for dieting was for a prolonged period, it was inevitable that various nutrient stores were depleted. The result was some sort of health compromise. The nature of the compromise and the consequences depended upon which nutrients happened to be depleted by the unique food choices of the dieter. What was required was a nutrient-complete source, which guaranteed nourishment and at the same time provided the least possible calorie levels so that a maximum rate of safe weight loss could be achieved. Liquid enteral feeds meet the nutrient criteria, but are usually designed to cause weight stability or even weight gain. These high-calorie levels are generally met by relatively high levels of fat. Simply reducing fat levels in enteral formulas solved the calorie problem. An ideal nutritional product with the absolute minimum of calories consistent with a healthy diet is achieved. The modern VLCD can be used with confidence, both in the reliability of the weight loss, and the safety of the monitored programmes. There are contraindications and medical issues that need to be understood, but under proper care the weight loss needs of seriously overweight patients can be met.

Help is available and simple to use

An expanding network of pharmacists are 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 a professional service. NICE recommends that specialists be used for extended VLCD treatment.5 These pharmacists are trained and experienced specialists in the use of VLCD. Suggest a pharmacist to offer your patients real help with their excess weight. This will even reverse the ever increasing prevalence of type 2 diabetes.

References

1. Sjöström D, Peltonen M, Wedel H, Sjöström L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000;36:20-5.

2. Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M. Ten-year trends in health related quality of life after surgical and conventional treatment for sever obesity: the SOS intervention study; Int J Obesity 2007;31:1248.

3. Stunkard A, McLaren- Hume M. Results of treatment for obesity (a review of the literature and report of a series). AMA Arch Intern Med 1959;103:79-85.

4. Saris WH. Very-lowcalorie diets and sustained weight loss. Obes Res 2001;9:295S-301S.

5. MIMS. NICE publishes guidance on overweight and obesity. London: MIMS; 2007.

PDF version: 4-4-Treating-overweight-patients

TYPE 2 DIABETES: SUGGEST A PHARMACIST INSTEAD OF A PHARMACEUTICAL

Type 2 diabetes is no longer an adult onset disease. Obesity is being seen in younger and younger people. There is a causal connection so people are calling it “diabesity”

It is time to stop wringing our collective hands about type 2 diabetes and do something about it. In a well researched editorial in this issue of Nursing in Practice (page XX-XX), Dr Song points out the frightening prevalence of type 2 diabetes and the terrible consequences of the disease. His comments add another page of literature to the existing pile, pointing out that this lethal disease is being seen in younger and younger age groups and treatment with a vast array of drugs does not appear to be solving the problem. He recognises the relationship to excess weight, but typically, really treating the weight is not one of the options considered. Why not? What could be the excuse? Could it be a lack of confidence in the means for treating obesity?
Obesity is not only treatable in theory, it is currently being treated effectively by more than 500 pharmacists in the UK and Ireland. Many of the cases being treated were patients with insulin resistance and/or type 2 diabetes. In patients with diabetes, it was necessary to get the prescribing doctor to stop the hypoglycaemic medication prior to dieting, because the blood sugar comes down very quickly, generally in about three days, and with continued weight loss, it seems to stay down, even with some weight regain. That’s it. No further story.
We are not in favour of the Atkins diet for many sound biological reasons, but when you consider the massive amount of money from vested interests and the well orchestrated expert opinion massed against the Atkins diet, you realise why the only tolerated solution will ultimately be pharmacological. But pharmacology cannot yet deal with obesity. A few kilograms of weight loss over an extended period has little impact on either the weight or disease. Fat people need to lose a lot of weight and playing with a few kilograms of glycogen and water loss is a waste of time and certainly not worth the risk of the side-effects.

Excessive weight

Excessive weight is the cause of 95–98% cases of type 2 diabetes and is contributory to hypertension. Weight loss is an effective treatment as it reduces blood pressure in most overweight people. Weight loss improves blood lipid profiles, ameliorates pain in arthritic patients, improves respiratory problems from apnoea to asthma, increases fertility and improves quality of life immeasurably.

Modest reductions in calories could theoretically result in weight loss. Of course, the modest reduction has to be from the equilibrium level, not from current intake. There is a maximum rate of weight loss for any individual. A total fast requires that all the calories necessary for life come from the body reserves, there can not be any greater rate of weight loss for any individual.

Nutritional products

A total fast provides no nourishment and therefore is not acceptable. A diet has to supply adequate essential amino acids, essential fatty acids, vitamins, minerals and trace elements, in order to keep the dieter healthy. What is needed is a nutrient complete source, which guarantees nourishment, that at the same time provides the least possible calorie levels so that a maximum rate of safe weight loss can be achieved. Liquid enteral feeds meet the nutrient criteria, but are designed to cause weight stability or even weight gain. These high calorie levels are generally met by relatively high levels of fat. Simply reducing fat levels in enteral formulas solves the calorie 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.
There are now over 500 pharmacies in the UK and Ireland offering monitored weight loss programmes using Lipotrim, joining the many UK GPs offering Lipotrim to their patients. Suggest a pharmacist to offer your patients real help with their excess weight and reverse the scandal of an ever increasing prevalence of type 2 diabetes.

PDF version: 4-2-not-a-pharmaceutical

FREEING PATIENTS FROM THE TYRANNY OF FOOD DURING WEIGHT LOSS

When 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. Lipotrim weight maintenance programmes assist your patients in long-term weight management

Weight maintenance requires control of eating behaviour over a sustained period of time. While willpower can often help people lose weight over a short defined period, control for the months, years or even decades required for maintenance is quite a different story. Loss of weight by any means confers absolutely no lasting gift for weight maintenance. Weight
loss, however achieved, is only the beginning of the treatment, not the end point.
A person who has lost weight has to cope with the fact that he calorie requirement to maintain a lighter body is lower than they had become accustomed to eating. Returning to prediet eating behaviour will result in an early return to prediet weight. There is no “set point”. There is only a prolonged habitual approach to food choices and portion sizes that satisfy.
What usually surprises Lipotrim dieters, is the sudden freedom from food tyranny in conjunction with the appearance of urinary ketones, which are induced by a very low calorie, low carbohydrate intake and sustained long enough to deplete body stores of glycogen and force the utilisation of stored fat. Weight loss with Lipotrim is certain due to the large calorie
gap between intake and any level of expenditure. What allows the dieter to lose substantial weight, however, is the
prolonged freedom from the desperate drive to eat. This freedom is lost as soon as food is reintroduced.

 

Lipotrim weight maintenance formulas are not simply meal replacements
One of the most dramatic metabolic consequences of substantial weight loss is an improvement in insulin resistance.
In the immediate post-diet condition there is usually a continued excessive secretion of the now normally functioning
insulin, which can lead to mild hypoglyceamia. This is interpreted by the patient as a strong signal to eat.
Unless this is blocked, the dieter will overeat and regain weight. Maintenance requires calming these food cravings. Slowing the absorption of glucose from the gut into the bloodstream is the surest way to minimise the insulin response and reduce the recurrence of cravings subsequent to a meal.

Using what is well known to solve a major problem
Reliable and controlled slowing of the absorption of glucose from the gut is achieved by the addition of soluble fibre to a meal. Nourishment is still important, however, especially when food intake will become restricted. The addition of a complete micronutrient mix to the potent soluble fibre assures the provision of the complete complement of essential amino acids, fatty acids, trace elements, vitamins and minerals that one would expect to be provided by a full meal. The result is a greatly enhanced record of post-diet weight stability.
Weight management is enhanced in pharmacies
Many practices treat their own patients with Lipotrim, and the weight loss successes with their major clinical benefits more than justifies the practice time. The difficulty comes with justifying practice time and resources for patients who have achieved weight loss and are now both healthier and trying to maintain a normal weight. The expectation that this patient will sustain the weight loss without considerable help is naïve. Pharmacy-based programmes are ideal for the varying needs of patients. Obesity prevention, treatment and long-term management is a pharmacy health promotion service. Care of patients during weight loss, is ideal when carried out by the pharmacist who understands the implications of diseases or drug treatments that may interact with the weight loss programme. But, it is in the postdiet stage that the pharmacist is best placed to provide the essential longterm guidance, support and education that will increase the length of time that the weight loss is maintained. Pharmacists armed with the Lipotrim programme can assist your overweight patients cope with long-term weight management.

PDF version: 4-1-freeing-patients