Tag Archives: weight reduction

GP/PHARMACIST: SYNERGY FOR OBESITY CONTROL

In order for weight loss programmes to be successful, it is essential to conduct post-diet monitoring and provide the overweight patient with long-term support. The Lipotrim pharmacy-based programme, therefore, encourages an interactive approach with GPs to ensure successful, sustained weight management

it seems easy to justify practice time and resources to assist overweight and obese patients lose weight. The link to type 2 diabetes alone is sufficient. With rapid weight loss, normalisation of blood sugar levels is achieved in days. 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 by losing the same amount of weight more slowly. Almost 50% of hypertensive patients can reduce drug treatments with weight loss. Surgical interventions can be scheduled when substantial weight is lost. Fewer antidepressants 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. 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.
While willpower can often help people lose weight over a short defined period, upholding control for the months, years or even decades required for maintenance is quite a different story. Loss of weight by any means confers absolutely no lasting 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. A difficulty comes with justifying practice time and resources for a patient who has achieved weight loss and is now both healthier and at a normal weight. The expectation that this patient will sustain the weight loss without considerable help is naïve.

Lipotrim pharmacy-based programmes are ideal for the varying weight management needs of patients. Obesity prevention is part of the pharmacy complement of 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 the 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 and asthma. It even impacts upon programmes for smoking cessation. The success of the Lipotrim pharmacy-based programmes in dealing with weight loss and maintenance should not be overlooked.

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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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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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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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