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

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.

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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