“Fat people are just greedy, says BMA chief” – www.telegraph.co.uk, 4 August 2007. “Doctor tells fatties to eat less” – www.thesun.co.uk, 3 August 2007. These kinds of headlines are avoidable

There is now close to a 30-year history of safe and effective worldwide usage of nutrient-complete total food replacements based upon the concept of low-fat nutrient-complete enteral feeds (VLCD). The enormous volume of scientific and medical literature has been thoroughly evaluated by expert committees and they have been recognised as safe and in some cases, such as type 2 diabetes, more effective than standard weight loss methods.

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. These pharmacists are trained and experienced specialists in the use of VLCD.
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 patients with arthritis, increase the fertility of women and relieve sleep apnoea. Weight loss can provide an opportunity for patients to be considered for elective surgery. It can decrease the need for antidepressants, make exercise more possible, thus improve cardiovascular
health, and can vastly improve the quality of life for patients in a prejudiced and intolerant world.
Minimal calorie gap diets are not always successful. For example, in the 1959 classic study of the published outcomes from the best weight loss programmes, Stunkard showed that regardless of the programme for weight loss, or the expertise of the clinic, after one year 95% had put back on all the lost weight.1 After two years 98% and by five years virtually all of the dieters had put the weight back on.
VLCD has a vastly better, well-documented, record for weight maintenance.
The idea that reducing calorie intake to a sufficiently low level to encourage a more rapid loss of weight, was somehow harmful, can be directly attributed to the fact that the distribution of essential nutrients in ordinary foods makes it very difficult to create a nutrient-complete diet under conditions of food restriction. It is impossible to achieve a nutrient-complete diet at intakes below 1,200 calories.

Once 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 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. Supplying the essential nutrients in a preprepared mixture, as in an enteral feed,
assures that nutrient deficiencies do not occur. As for energy, the dieter has ample stores of energy in the fat stores of the body – about 37,000 calories in each stone of excess fat weight. These calories are readily available. None are really required from the outside, with the exception of those nutrients in the formula that notionally have a calorie value (such as the essential aminoacids and the essential fatty acids). A proper calorie gap provides reliable and continuous weight loss, which is motivating in itself, but has also been shown to provide better glycaemic control in people with diabetes
than the same weight loss achieved more slowly.
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 the care of an experienced pharmacist, the weight loss needs of seriously overweight patients can be met.

reference
1. Stunkard A, McLaren-Hume M. Results of treatment for obesity. Arch Int Med 1959; 103:79-85.

PDF version: 5-3-medical-concern

Over 70% of the middle-aged UK population has a weight problem.Healthcare professionals cannot wait for new pharmaceutical solutions: action is needed now, if only to cope with “diabesity” – a very descriptive addition to the language

there is a lengthy list of common medical conditions that are either caused by or exacerbated by obesity. At the very top of that list is type 2 diabetes, which is virtually 100% reversibly related to excess weight. Treating the weight is treating the disease. Treating the weight could also be considered as preventing the disease. By 2010, three million people will be diagnosed as having diabetes, and 80% of them will die prematurely from cardiovascular disease.1 Type 2 diabetes is even increasing in children; the condition is considered serious enough by NICE that surgical intervention is being countenanced for children. Most of the agents used in diabetes treatment are known to cause an increase in weight.
Current treatment protocols often encourage immediate selection of treatments that invariably result in yet further weight gain and perpetuation of the disease.
Morbid obesity minus 5% is still pretty fat
What advice should we give to a 23-stone patient? Should the advice be different if this patient was 25 stone a year ago? There is a very high probability that clinical judgement would not recognise much difference. This patient is still dangerously fat, despite having lost the 5% of initial weight that may have been the treatment expectation.

Even worse, an obese patient will usually shift 5% of body weight or more of stored glycogen and water upon dieting. Fat loss at this level can be essentially nil. With repletion of glycogen stores upon termination of the “diet”, the lost weight can rapidly return. It can almost seem as though there is a “set point” for body weight.

Being effective with obese patients
Pharmacists are already proving that substantial weight loss and long-term weight maintenance can be an expected norm under pharmacy conditions. Weight loss will drastically reduce the advance of type 2 diabetes. It will help deal with hypertension. It will permit patients to gain access to elective surgery. Excess weight is a common and powerful constraint on quality of life. It is in the best interest of patients and the NHS as a whole to support and encourage
initiatives in managing body weight.
It is also reasonable to expect clinically meaningful results for obese patients. While any weight loss can be argued to improve relative risk of diseases or premature death, patients anticipate real help from medical professionals. Before selecting a course of treatment, determine whether the published results for the treatment or previous experience provide a realistic expectation that the patient really will lose sufficient weight and not be faced with the probability
of nutrient deficiencies. The need is to reduce food intake sufficiently; to use up enough previously eaten calories that
are now stored as fat, and at the same time prevent malnutrition – the human body requires a full complement of nutrients.

Patients need to accept a substantial reduction in calorie intake
Patients would love to find a way around some very simple laws of physics, but sadly it is impossible. In order to lose weight they really have to eat fewer calories than they are using, regardless of whether the calories are from carbohydrates, fats or proteins. It takes an enormous amount of physical effort to use up the calories (3,500kcal) in a single pound of body fat. Since a mile run only consumes about 100kcal, a 35-mile run is required. The only practical means of dealing with a substantial weight problem is by severely restricting intake. Increased activity levels are very important in the long term but are more possible as the patient achieves a reasonable weight.

Since food restriction has much in common with restriction in other manifestations of addiction, withdrawal is not simple, especially in an environment where there is continued presence of the substance of abuse. Customary approaches to weight management are failing worldwide, leading to much wringing of hands and apportioning
of blame. At the same time, many of your pharmacy colleagues are quietly having an impact. If there really are going to
be three million diagnosed cases of type 2 diabetes in the UK in 2010, they could really use some help.

reference

1. Practice: parentlal role in ending child obesity. GP Magazine 2005;11:38.

PDF version: 5-2-helping-obese-patients

There is now a pandemic of obesity, and the problem is getting worse instead of better. Would you know how to offer help that is worth the time and effort? Or would you simply reiterate the same platitudes that have been so ineffective over the years? Stephen Kreitzman and Valerie Beeson explain how Lipotrim can help

Many weight loss programmes either fail outright or provide so little weight loss beyond glycogen and its associated water losses that cavalier attitudes to weight loss are commonplace. The loss of significant weight cannot be treated so lightly. A type 2 diabetic on oral agents, for instance, will need to stop medication, ideally prior to dieting, since the blood sugar will normalise within the first few days of treatment. Continued medication may induce a hypoglycaemic reaction. Some people should not diet at all; others should diet with only the closest monitoring. Virtually all medical discussions of obesity begin by listing the medical consequences of excess weight. When weight loss is real and significant, there are physiological changes and therefore monitoring and control are justified.
There are now more than 300 pharmacies in the UK and Ireland, offering monitored weight loss programmes using Lipotrim, joining the thousands of UK GPs and hospital consultants offering Lipotrim to their patients. You can offer your patients help with their excess weight by simply guiding them to a local, trained pharmacist.
Excessive weight is the cause of disease in almost all cases of type 2 diabetes. Weight loss is an effective treatment. Excessive weight is contributory to hypertension. Weight loss reduces blood pressure in these 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.

If a person is overeating by 2,000 calories a day (very common in the obese), a small reduction in calorie intake will not cause weight loss. A reduction of a single calorie per day from the level in equilibrium with expenditure, however, will, in theory, result in weight loss. The dieter will have to be patient, however, since it will take 3,500 days (10 years) to use up the calories in a single pound of body fat at the rate of one calorie a day.
At the other extreme, 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. A total fast violates the principle of need for nourishment and therefore supplementation is required. A diet has to supply adequate essential amino acids, essential fatty acids, vitamins, minerals and trace elements, in order to keep the dieter healthy. A total fast therefore cannot be a valid treatment for obesity.
What is needed is a nutrient complete source, which guarantees nourishment but 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 met by relatively high levels of fat. Enteral feeds are used for prolonged periods without problems.
The simple idea of 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. Lipotrim is an example of such a product.
You can offer your patients real help with their excess weight. Get the facts, share them with your patients. Weight is a serious issue.

Stephen Kreitzman PhD RNut UK Registered Nutritionist
Valerie Beeson Clinical Programme Director
Howard Foundation Research Ltd Cambridge UK

PDF version: 5-1-getting-results