Tag Archives: VLCD

TREATING DIABETES: RAPID CONTROL WITH WEIGHT LOSS

There is now a pandemic of obesity, and the problem is causing increasing levels of type 2 diabetes. Cooperation with effective pharmacy weight loss programmes can reliably provide rapid and potentially long-term clinical benefits from weight loss. Stephen Kreitzman and Valerie Beeson explain how Lipotrim can help

diabetes is a progressively debilitating disease, often requiring increasingly aggressive therapy. The treatment protocols with oral hypoglycaemics usually lead to increasing body weight. The increased weight degrades insulin sensitivity and can ultimately lead to a need for insulin. With insulin, a common outcome is yet further weight gain, and the disease gets increasingly worse. This entire cascade of events can be avoided.
There are really two basic facts to consider. The first is that type 2 diabetes is a disease that has a primary aetiology, which is close to 100% reversibility 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.

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 2,000 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.
There is also extensive literature on the beneficial effects of weight loss on cardiovascular risk factors, on blood lipid profiles and on blood pressure. Managing weight in practice, however, can be time consuming. The beneficial results from substantial and rapid weight loss on the glycaemic control and the cardiovascular risk factors more than justify consideration of this approach. Cooperative efforts with local pharmacists, however, benefit patients, pharmacists and also the primary care
providers.
Weight is extremely important to patients and has a critical influence on the clinical course of type 2 diabetes. It would appear prudent and considerate to give diabetic patients an opportunity to lose weight using Lipotrim under your own care or encourage them to seek care from a local pharmacist.

Stephen Kreitzman PhD RNutr, Valerie Beeson Clinical Programme Director

PDF version: 4-TREATING-DIABETES-RAPID-CONTROL-WITH-WEIGHT-LOSS.pdf

WEIGHT MANAGEMENT IS A MEDICAL CONCERN

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

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

An expanding network of pharmacists are offering a range of treatments for weight problems. They have the training,
the respect of the public, the contact hours and the desire to offer weight management as a professional service. NICE
recommends that specialists be used for extended VLCD treatment. These pharmacists are trained and experienced specialists in the use of VLCD.
Weight loss is more than a cosmetic issue. Weight loss can lower blood pressure, normalise blood lipids, practically
eliminate type 2 diabetes, reduce the severity of asthma, bring relief to patients with arthritis, increase the fertility of women and relieve sleep apnoea. Weight loss can provide an opportunity for patients to be considered for elective surgery. It can decrease the need for antidepressants, make exercise more possible, thus improve cardiovascular
health, and can vastly improve the quality of life for patients in a prejudiced and intolerant world.
Minimal calorie gap diets are not always successful. For example, in the 1959 classic study of the published outcomes from the best weight loss programmes, Stunkard showed that regardless of the programme for weight loss, or the expertise of the clinic, after one year 95% had put back on all the lost weight.1 After two years 98% and by five years virtually all of the dieters had put the weight back on.
VLCD has a vastly better, well-documented, record for weight maintenance.
The idea that reducing calorie intake to a sufficiently low level to encourage a more rapid loss of weight, was somehow harmful, can be directly attributed to the fact that the distribution of essential nutrients in ordinary foods makes it very difficult to create a nutrient-complete diet under conditions of food restriction. It is impossible to achieve a nutrient-complete diet at intakes below 1,200 calories.

Once traditional food diets were attempted below 1,000 calories, dieters were put at risk. When the need for dieting
was for a prolonged period, it was inevitable that nutrient stores were depleted. The result was some sort of health compromise.
The nature of the compromise and the consequences depended upon which nutrients happened to be depleted by the unique food choices of the dieter. Supplying the essential nutrients in a preprepared mixture, as in an enteral feed,
assures that nutrient deficiencies do not occur. As for energy, the dieter has ample stores of energy in the fat stores of the body – about 37,000 calories in each stone of excess fat weight. These calories are readily available. None are really required from the outside, with the exception of those nutrients in the formula that notionally have a calorie value (such as the essential aminoacids and the essential fatty acids). A proper calorie gap provides reliable and continuous weight loss, which is motivating in itself, but has also been shown to provide better glycaemic control in people with diabetes
than the same weight loss achieved more slowly.
The modern VLCD can be used with confidence, both in the reliability of the weight loss, and the safety of the monitored
programmes. There are contraindications and medical issues that need to be understood, but under the care of an experienced pharmacist, the weight loss needs of seriously overweight patients can be met.

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

PDF version: 5-3-medical-concern

WEIGHT MANAGEMENT: HELPING OBESE PATIENTS

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

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

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

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

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

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

reference

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

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

TREATING WEIGHT IN THE PHARMACY: GETTING RESULTS

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

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

If a person is overeating by 2,000 calories a day (very common in the obese), a small reduction in calorie intake will not cause weight loss. A reduction of a single calorie per day from the level in equilibrium with expenditure, however, will, in theory, result in weight loss. The dieter will have to be patient, however, since it will take 3,500 days (10 years) to use up the calories in a single pound of body fat at the rate of one calorie a day.
At the other extreme, there is a maximum rate of weight loss for any individual. A total fast requires that all the calories necessary for life come from the body reserves. A total fast violates the principle of need for nourishment and therefore supplementation is required. A diet has to supply adequate essential amino acids, essential fatty acids, vitamins, minerals and trace elements, in order to keep the dieter healthy. A total fast therefore cannot be a valid treatment for obesity.
What is needed is a nutrient complete source, which guarantees nourishment but at the same time provides the least possible calorie levels so that a maximum rate of safe weight loss can be achieved. Liquid enteral feeds meet the nutrient criteria but are designed to cause weight stability or even weight gain. These high calorie levels are met by relatively high levels of fat. Enteral feeds are used for prolonged periods without problems.
The simple idea of reducing fat levels in enteral formulas solved the calorie problem. An ideal nutritional product with the absolute minimum of calories consistent with a healthy diet is achieved. Lipotrim is an example of such a product.
You can offer your patients real help with their excess weight. Get the facts, share them with your patients. Weight is a serious issue.

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

PDF version: 5-1-getting-results

TREATING OVERWEIGHT PATIENTS: WHAT ARE THE OPTIONS?

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

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

Tell her to exercise?

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

Cut back a little to lose weight slowly?

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

Faster weight loss is actually better

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

Help is available and simple to use

References

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

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

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

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

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

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

COULD LIPOTRIM VLCD TREAT YOUR OBESE DIABETIC PATIENTS AND REDUCE YOUR PRESCRIBING COSTS?

The NHS is reported to be spending £9 billion a year treating diabetes ineffectively File on Four. BBC Radio 4 21 February 2012.)

Perhaps the most important contributory cause to the rise in diabetes in recent years is overweight and obesity, yet a cost-effective, evidence-based option for treating the condition appears to be being overlooked. Rapid weight loss using a very low calorie diet (VLCD) regime has been shown to normalise blood sugar levels within a few days, requiring withdrawal of hypoglycaemic medication. 1,2 VLCD also lowers the risk factors for cardiovascular disease.

Bariatric surgery is another recognised method of weight reduction for obese patients with diabetes. However, the effect
on blood sugar is stronger with VLCD than with bariatric surgery as post-surgical nutrition includes a significant amount of carbohydrate, thus preventing the rapid utilisation of blood sugar and glycogen stores fundamental in a ketogenic VLCD. Furthermore, while there are around three quarters of a million patients who meet the NICE criteria for eligibility for bariatric surgery, the health system barely begins to meet the demand and last year less than 9000 operations, NHS and private combined, were performed.

Lipotrim is a well-established VCLD programme, supervised by GPs or pharmacists, which has been running successfully for over 25 years. GPs can monitor their patients on the programme themselves, although the monitoring task is usually provided by pharmacists who also supply the Total Food Replacement products. The programme has the additional advantage of being cost neutral to the NHS as the products are not ordinarily prescribed, while the cost to patients is usually more than compensated by the reduction in their food bills. Lipotrim refeeding and maintenance programmes are available for patients to maintain their weight at the reduced level once a target has been achieved.

Abundant evidence is available of the success of Lipotrim VLCD programmes run in UK pharmacies. More than 2000 pharmacies offer the service and many record their patients’ progress using Patient Tracker software, which produces
detailed audits providing substantial evidence of efficacy across a wide spectrum of patients and medical conditions. For example, audit results from 400 patients treated in one pharmacy have recorded an average weight loss of 11% across all clients after three or more weeks on the Lipotrim programme. 3
Percentage of initial weight lost by patients in this group reached as high as 37%. Average percentage weight loss rose with increasing BMI at outset, from 9% loss in clients with a BMI of 25-30, to 13% with starting BMI of 35-40 and 21% for those with starting BMI of 45-50. The figures also show that weight losses were maintained during refeeding and maintenance after dieting. There is also evidence from the Tracker that an average weight loss of around 14% can be
achieved on the Lipotrim programme by hypothyroid patients, who generally experience great difficulty with weight
management. And average weight losses of 12-13% in patients with hypertension and depression, conditions to which
excess weight can be a contributory factor, have also been shown.

For further information, contact Valerie Beeson, Clinical Programme Director, Howard Foundation Research Ltd. Cambridge UK. E-mail: obesity@lipotrim.demon.co.uk. Phone:01223 812812.

References
1. Paisey RB, et al. An intensive weight loss programme in established type 2 diabetes and controls: effects on weight and
atherosclerosis risk factors at 1 year. Diabet Med.1998; 15:73-9.
2. Paisey RB, et al. Five year results of a prospective very low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet. 2002;15:121-7.)
3. Pharmacist Gareth Evans, Waistaway Ltd. Data on file.

PDF version:3-2-BMJ-May-2012

DIABETES AND OBESITY: HAVE YOU THOUGHT ABOUT LIPOTRIM?

“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 risk. Young 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

GPs already know this and that diabetes, 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. 1 A five-year follow-up study confirmed that VLCD treatment was safe and effective in overweight diabetic subjects.2 It has also been shown that normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes is achieved by VLCD dietary energy restriction.3
Very low calorie diets and bariatric surgery are demonstrably the most effective weight loss methods for diabetic patients. Ultimately, it is the loss of the excess weight that leads to long

term improvement in insulin sensitivity and blood sugar control. With both VLCD and surgery, there is an immediate substantial reduction in the oral consumption of either carbohydrates or substances that can be readily converted to carbohydrates and, as a result, the metabolic response is rapid. Circulating glucose and mobilised glycogen stores are rapidly consumed and generally depleted within about 3-4 days, reducing blood glucose to normal levels. The reduction is so dramatic that oral hypoglycaemic agents must be withdrawn prior to the start of a VLCD programme. Rapid weight loss, with reasonable long term weight management, can put diabetes into long term remission. Both VCLD and bariatric surgery are approved by NICE as options for the treatment of obesity, but the advantages of a VLCD such as Lipotrim are often overlooked. A Lipotrim regime is not accompanied by the problematic aspects of bariatric surgery: high morbidity and mortality risk, prohibitively high cost, possible post operative complications and, in consideration of the large numbers of severely overweight people with or without diabetes, extremely limited availability. Lipotrim is not available on the NHS so treatment costs the NHS nothing, but patients are not out of pocket as the costs of the diet are no more, and can be less, than the costs of the food it replaces.

Lipotrim is supplied in more than 2000 pharmacies nationwide. Overweight or obese patients taking medication for diabetes can only start on the Lipotrim programme with the cooperation of their GP. Potential dieters undergo an initial assessment by the pharmacist. The dieters must return to the pharmacy each week to collect their supplies, when the pharmacist monitors their progress and to check compliance with the diet. Once the target weight is attained, patients can elect to use specially formulated Lipotrim maintenance products along with healthy eating , which effectively assists post diet calorie control. Pharmacists also provide lifestyle advice and support to help prevent the lost weight from being regained. Each patient’s progress is recorded and many pharmacists use the Lipotrim Pharmacy Patient Tracker software, which audits the results of patients’ dieting and illustrates the patient’s progress in graphic form. Pooled audits from pharmacies have demonstrated their outstanding success in helping patients to lose weight and achieve remission from diabetes.
There is really no excuse for the situation reported by the File on 4 programme. Many patients can be helped to escape diabetes permanently by following a VLCD regime, and while not every diabetic patient may be able to defeat the addictive lure of a subsequent return to overeating, many can. But even for those who cannot, the time away from the condition allows for dealing with other medical problems and an improved quality of life. So, it is surely worth giving the patients a chance and Lipotrim a try.
For further information, contact Valerie Beeson,
Clinical Programme Director, Howard
Foundation Research Ltd. Cambridge UK.
E-mail: obesity@lipotrim.demon.co.uk.
Phone:01223 812812.

References
1. Paisey RB, et al. An intensive weight loss programme in established type 2 diabetes and controls: effects on weight and atherosclerosis risk factors at 1 year. Diabet Med.1998; 15:73-9.
2. Paisey RB, et al. Five year results of a prospective very low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet. 2002;15:121-7.
3. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia. 2011;54:2506-14.

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.

PDF version: 2-5-successful

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

PDF version: 2-4-obesity-pandemic

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

Lipotrim Resources

VLCD diet resources from Lipotrim