Monthly Archives: December 2012

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.

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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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PHARMACIES LEAD THE WAY IN OBESITY MANAGEMENT

Pharmacists can play an important role in weight management.
And there’s evidence to support their effectiveness.

Early in October 2010, the National Obesity Forum Conference in London heard a presentation by Fin McCaul, the pharmacist at Prestwich Pharmacy in Manchester. Mr McCaul, who is also chair of the Independent Pharmacy Federation, was presenting his pharmacy’s outstanding results in treating overweight and obesity at the pharmacy. His paper, ‘Options for the orbidly obese’, was based on 1,148 overweight patients with a median initial BMI of 33.6 kg/m2
enrolled into the Lipotrim weight management programme. Of these patients, 25 per cent were morbidly obese with a BMI >40 kg/m2. At the time of audit, during which many patients were still actively dieting, the median BMI had decreased to <30 kg/m2. Results showed that 94 per cent of the dieters lost more than 5 per cent of their pre-diet weight, 47 per cent lost more than 10 per cent, and 21 per cent of the patients lost more than 20 per cent. The presentation highlighted the impressive weight loss results being achieved in pharmacy. Given that the organisers of the programme chose to position the presentation in the section of the conference devoted to bariatric surgery, Mr McCaul concentrated his results on the subset of the dieters who were of greatest relevance to the surgeons – the morbidly obese. Morbidly obese people are generally considered ‘heart sink’ cases; they are notoriously difficult to treat. The reason is largely due to the common chemistry with other examples of substance abuse. Recognition of this common chemistry is now leading to the development of weight management strategies involving drugs which are important in the treatment of alcohol and drug addictions.

1-6aAdvantages of weight loss
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 the fertility of women hoping for pregnancy, relieve sleep apnoea, and provide an opportunity for patients to be considered for Pharmacists can play an important role in weight management. And there’s evidence to support their effectiveness. elective surgery. Loss of weight can decrease the need for antidepressants, make exercise more possible – thus improving cardiovascular health, and can vastly improve the quality of life for patients. Methods of treatment, however, are not universally agreed upon. Somewhat unsurprisingly, bariatric surgeons tend to favour the surgical approach to weight loss. According to the Department of Bariatric Surgery at Imperial College, the current burden of morbid obesity in the UK is approximately 720,000 patients who meet NICE criteria for eligibility for surgery. In 2008 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 and fall far short of the treatment needs of the seriously overweight population. Most surveys estimate that in the UK about 60 per cent of the population are overweight and about 30 per cent are already obese. Assuming a 60 million UK population, the number of people with a weight problem calculates to 36 million overweight and 18 million obese. Treating this many people surgically is unrealistic, to say the least. In addition, there is an increasing tendency for people to seek less expensive or more readily available bariatric surgery abroad, which has led to an ethical dilemma for NHS specialists. The costs to the NHS of providing aftercare, expected free by UK citizens, or emergency subsequent surgery when procedures initiated abroad go wrong, can be unplanned for and a substantial drain on NHS resources2.
Pharmacists’ role
Bariatric surgeons (in the current absence of a selection of effective weight loss drugs) are increasingly attempting to convince the public and the professionals that surgery is the only method of effectively treating seriously overweight people. The evidence presented by Mr McCaul clearly demonstrated that there is a non-invasive treatment that can be as effective. Like the claims for remission of diabetes as a result of the surgery, diabetes remissions are obtained by pharmacists as well since it is the loss of weight that leads to the remission. Usually, the blood sugar control is so rapid that it has become mandatory to get the doctor’s cooperation in stopping oral hypoglycaemic medications prior to the patient dieting. Without this step, patients are not permitted to participate in the Lipotrim programme. The results presented for this difficult cohort of morbidly obese patients was suitably impressive. These were very large individuals indeed, with half presenting with a BMI above 45 – the heaviest just below BMI 70. From this subset of 267 patients, the results reported were:

  • Median BMI was 45.1 at enrolment;
  • 237 patients lost over 5 per cent of pre-diet weight;
  • 141 had lost over 10 per cent of pre-diet weight;
  • 34 patients had lost over 20 per cent.

The programme at Prestwich is only one of more than 1,500 UK pharmacies treating overweight patients in this way. What’s more, the introduction of Lipotrim’s patient tracker software now permits on-demand audits of the results obtained by each pharmacy – essential for demonstrating effectiveness for commissioning requirements. Mr McCaul’s audience – primarily surgeons – listened for the most part in attentive silence, but the questions put to him at the end of his presentation were extremely revealing and illuminating. One overly distressed questioner was seriously worried that a few weeks of what is essentially a nutrientcomplete enteral feed (to effectively treat morbid obesity and its medical consequences) would compromise the patient’s relationship with food and cause chaos in the family dynamic. As she summed it up: there was a risk of “demonising food”. Leaving aside for a moment the point that bariatric surgery is an invasive and dangerous procedure that results in a state of permanent malnutrition, it is worth remembering that morbidly obese individuals generally have a very destructive relationship with food. To these individuals, food is a substance of obsession and addiction, and eating is a compulsive behaviour. Modifying the patient’s relationship with food is arguably a very worthwhile goal.

One of the more disturbing post-surgical problems (being widely reported from the US, where large numbers of surgeries are performed) is the unexpected and unwelcome problem of addiction transfer. A quick Google search unearths the massive scope of the problem, in which the loss of the ability to eat (due to weight loss surgery) is apparently leading to the development of substitute addictions – to alcohol, drugs and other destructive activities.

1-6bTotal food replacement
The total food replacement programme owes its success in no small part to the first principle that – instead of inducing malnutrition – the formulated enteral feeds are generally much more nutritious than the ordinary food choices of the
patients. As all essential nutrients are provided, the patients remain healthy throughout their programme. Where there
is a component of food abuse associated with the weight problem, the nutrient formulas are the only way that normal
foods – the addictive substances – can be safely eliminated so that the dieter can have a better chance of success.
An expanding network of pharmacists is offering a range of treatments for weight problems. Pharmacists have the training, the respect of the public, the contact hours and the desire to offer weight management as a professional service.
The National Institute for Health and Clinical Excellence (NICE) recommends that specialists be used for extended treatments involving total food replacement. Pharmacists that join this programme are trained and experienced specialists in this area.
Unlike surgery, there is no cost to the NHS, and no serious sideeffects.

The cost to the patient is less than the money a morbidly obese individual will have been spending on food, and the level of weight loss is sufficient to put type 2 diabetes into remission. The documented and audited successes of these dieters is a welcome testament to the leadership role that pharmacists are taking by providing important healthcare services to their community

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THROWING MONEY AT UK OBESITY

The government is proposing new initiatives to combat the disturbing statistics about obesity in the UK population. With this in mind, Stephen Kreitzman and Valerie Beeson look into very low-calorie diets (VLCDs) as an option in professional weight management

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WONDERFUL INITIATIVES ARE FINALLY COMING THICK and fast. The UK government is apparently committing to spending substantial amounts of unbelievably scarce public money in an attempt to combat the plague of overweight and obesity’. At the time of writing, there have been headline stories predicting that by 2050, nine out of ten people in the UK will be overweight or obese’. It has also been reported that 9,000 people are dying each year from the direct consequences of obesity’ and that the NHS is spending about Lim each hour treating diabetes alone’, a disease that is related to excess weight. Even more disturbing are the statistics about the massive levels of type 2 diabetes in children5.5. Certainly something in these revelations should be dramatic enough to attract the attention of every thinking person in the UK, regardless of their interest in medicine. For those entrusted with the nation’s health, however, there has to be a massive rejoicing at the proposed initiatives.
There are cynics among us. however, who might ask annoying questions relating to the specifics of how the money is intended to be spent — about whether the approximately 18 million people (about 30 per cent of the population) who are already obese will be sufficiently helped, or whether the average 25 people who are dying each day will be saved. Will new bicycle paths and less expensive vegetables in the shops solve the problem for those overweight enough for it to be a health risk?
Change may well result from these efforts, and future generations may well be discouraged from becoming overweight, but we cannot justify ignoring the needs of those who are already seriously overweight or indeed suffering from the medical consequences of that weight. The difficulty is, however, that there is so muchexisting overweight and obesity that no public budget could possibly stretch far enough to cover the costs’.
Now that NICE has acknowledged the use of very low-calorie diets (VLCDs)8, it is time to extend the availability of this option to the selection of choices for professional weight management. There is certainly plenty of justification for helping overweight patients. Weight loss can lower blood pressure, normalise blood lipids, help tackle type 2 diabetes, reduce the severity of asthma, bring relief to arthritics, increase the fertility of women hoping for pregnancy, cure sleep apnoea, provide an opportunity for patients to be considered for elective surgery and decrease the need for antidepressants. It can also make exercise more likely and thus improve cardiovascular health, and vastly improve the quality of life for people in a prejudiced and intolerant world.
The World Health Organization (WHO) expects health professionals to help. The Department of Health expects doctors and pharmacists to deal with obesity; the media expect them to do something about excess weight. The patients want help. None of these pressures to deal with weight has taken into account the fact that currently six out of every ten patients is overweight and nearly half of these are obese. Treating the overweight in a GP surgery, despite its importance, can overwhelm practice resources very quickly.
The result is a plethora of weight loss nostrums, teas, magical exotic herbs and exploitive diets that at best are worthless, but at worst lead to the need for remedial medical care. An obese patient has a very limited capacity for exercise. To lose a pound of fat it is necessary to have a calorie deficit (below the weight equilibrium level) of 3,500 calories. Running a mile uses about 100 calories; therefore,expecting an obese patient to deplete fat stores with exercise is unrealistic, despite its cardiovascular value. p2r1

There is no secret or magic to weight management. Calories eaten have to be considerably less than those being used, for a sustained period of time. But professionals also understand that the continued health of the patient requires them to consume all the essential nutrients necessary for life and health. This becomes increasingly difficult as the amount of food consumed is reduced or as our treatments actively promote malabsorption. 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 humans, but none have 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 needed. So a myth arose that dropping calorie intake 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. Dieters were simply becoming 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 little need to eat more. They just need to get the essential nutrients. Supplying the essential nutrients in a pre-prepared mixture, as in an enteral feed, assures that nutrient deficiencies do not occur.

There is now close to a 30-year history of safe and effective worldwide usage of nutrient-complete total food replacement formulas 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 effective 9. An expanding network of health professionals in pharmacies 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 an expanded professional service. NICE recommends that specialists be used. It is worth looking into.

References
1. ‘Healthy Towns’ initiative to stave off rise in obesity (www.onmedica.com/NewsArticle.aspx?id=16ef1b9e-f6d7-459c-a137-25a4c91a54d0).
2. Nine out of 10 adults will be overweight by 2050 (www.telegraph.co.uk/health/3411540/Nine-out-of-10-adults-will-be-overweight-by-2050.html).
3. Obesity kills more than 9,000 Britons a year (www.telegraph.co.uk/health/3416041/Obesity-kills-morethan-9000-Britons-a-year.html).
4. Diabetes costs NHS £1 million an hour (http://itn.co.uk/news/57484b9a27425b18a8337e4170411cdc.html).
5. Middle-class families most likely to have obese children, says Government study (www.dailymail.co.uk/health/article-1085484/Middle-class-families-likely-obese-childrensays-
Government-study.html).
6. Diabetes UK Response To Change4Life Announcement (www.medicalnewstoday.com/articles/128996.php).
7. Obesity epidemic has potential to bankrupt State (www.irishtimes.com/newspaper/opinion/2008/1113/1226408581971.html).
8. MIMS. NICE publishes guidance on overweight and obesity. London: MIMS, 2007.
9. Saris WHM. Very-low-calorie diets and sustained weight loss. Obesity Research 2001; 9 (suppl 4): 295S.

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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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