Tag Archives: VLCD

ACHIEVING WEIGHT MAINTENANCE AFTER SUBSTANTIAL VLCD WEIGHT LOSS

DIABETES ACHIEVING WEIGHT MAINTENANCE

AFTER SUBSTANTIAL VLCD WEIGHT LOSS

S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist),V. Beeson & S.A Kreitzman Howard Foundation Research Ltd. Cambridge UK

WEIGHT MAINTENANCE AFTER WEIGHT loss is perfectly possible, but not often achieved by traditional hypoenergetic diet programmes. Considering the paucity of evidence to support the idea that there is maintenance benefit from a slow rate of weight loss and the considerable amount of contrary evidence, it is very surprising that this idea persists.There is now recognition that even bariatric surgery suffers from unexpectedly high rates of recidivism after initial weight losses; this should have already altered the widespread expectation that weight maintenance should necessarily follow successful weight loss.We have reached a stage where VLCD and bariatric surgery are available to produce sufficient weight losses to promote medical benefits.At the top of the extensive list of co-morbidities associated with excess weight is type 2 diabetes. In order for these medical benefits to be sustained as long as possible, rapid weight loss and a structured, effective, maintenance programme are vitally important.
Weight regain after dieting can result from a variety of causes.The simplest of these is also the most common.The physiological principle here is that early weight losses are almost entirely due to the utilization of sugar and glycogen.These carbohydrate fuels with their associated bound water are regained quickly after restoration of normal eating, There is only a minimal actual change in fat storage — only small amounts of fat weight are lost, even when there may be a reasonable amount of weight loss due to depletion of the stored glycogen and its associated water. Lack of attention to an appropriate, structured, re- feeding can lead to carbo-loading, in a manner similar to the effect sought by endurance athletes.The consequence to a dieter; however is an excessive repletion of glycogen with its substantial rebound hydration.This can often produce weight regain in excess of the weight lost, and is a common feature after intermit-tent calorie restriction.
With a correct refeeding strategy, weight maintenance is much more assured.’Carbo loading’ requires depletion of glycogen followed by intake of high glycaemic index carbohydrate foods. Athletes often consume pasta, but fruit, bread, cereals etc. are just as effective.The result is a rapid overload of stored glycogen, often more than twice the pre-depletion levels.When the additional glycogen becomes bound to water for storage, considerable weight gain can be achieved.This is not a problem for an endurance athlete who will soon utilize the extra glycogen, but a considerable blow to a dieter who has just sustained prolonged food restriction in an attempt to lose weight.
Evidence for weight stability during a week of properly structured refeeding is demonstrated from an audit of patients attending a pharmacy based programme.

Before After
Refeeding Refeeding
Valid cases 146 146
Mean BMI 27.45 27.39
Median BMI 26.63 26.57

While there are indeed some minor variations in individual stability of BMI following the re-introduction of normal foods and re-establishing normal glycogen stores, these differences are usually trivial.

“New NHS research has revealed the shocking toll of preventable deaths caused by just one medical condition — diabetes — which is causing 24,000 needless deaths a year in England alone. It’s not just the old and middle-aged who are at riskYoung women with diabetes are 6 to 9 times more likely to die than their age group overall. And many more young people who don’t die will develop life threatening diseases later due to failure to manage their blood sugar. Badly controlled diabetes can lead to kidney disease, heart conditions, or blindness. It’s also the cause of 5,000 amputations a year mainly of legs or feet.With around 3 million diagnosed sufferers known to the health service, diabetes is said to be costing the NHS £9 billion a year about a tenth of the total health budget.”
File on Four. BBC Radio 4, 21 February 2012

Fig. I Design:Studies were required to I) have been conducted in the United States, 2) have included participants in a structured weight-loss program, 3) have provided follow-up data with variables estimates for y. Primary outcome variables were weight-loss maintenance in kilograms, weight-loss maintenance as a percentage of initial weight loss, and weight loss as percentage of initial body weight (reduced weight).
Weight Maintenance after Dieting

Weight loss with VLCD is especially beneficial for minimizing recidivism after substantial weight loss
Weight recidivism, when substantial weight loss has been achieved, can represent a more fundamental physiological problem. It is becoming increasingly accepted that food can become a substance of abuse, and that it shares the pathways common to addictions associated with tobacco, alcohol and drugs. It is an extremely rare occurrence when addicts are able to slowly wean themselves from the abused substance. Stopping the substance of abuse is the most effective strategy for almost all addictions, but there are serious consequences associated with a total cessation of food intake. In cases where the weight problem has become substantial enough that addictive mechanisms are likely, a case may be made that very low calorie formula diets (VLCD) are the only weight loss method with any real chance of succeeding, especially into the critical post-diet period.With a nutrient complete formula replacing all traditional foods, there is interference with the addictive processes and the dieter has a greatly improved chance for successful weight maintenance. Evidence that VLCD confers bet-ter long term weight maintenance than traditional hypoenergetic balanced diets has been repeatedly published.A particularly careful assessment was published in the American Journal of Clinical Nutrition in 2001 by James Anderson and co-workers.The report “Long-term weight-loss maintenance:a meta- analysis of US studies” compared 5 year post diet maintenance from published structured weight loss programmes. As can be seen from figure I . above, from 29 published studies that met the inclusion criteria, there was considerably more weight lost by the VLCD

Fig. 2 Many pharmacies in the UK using the Lipotrim PatientTracker software also track weight maintenance after completion of the weight loss programme. Results from Pharmacist Gareth Evans, for example, emphasize that post diet changes in BMI are minimal for the vast majority of dieters.

studies. After 5 years, the VLCD subjects still sustained a greater weight loss than the initial loss from the hypocaloric balanced diet.The criteria are described in the study design.
Maintenance of the weight lost is particularly important when treating a patient with type 2 diabetes.With the combination of rapid weight loss and a reliable maintenance opportunity,
VLCD are a vitally important option for the management of diabetes.
GPs already know the extent of the problem. Diabetes in particular, fuelled by an epidemic of overweight and obesity, is undermining the nation’s health. But it has been shown that with the aid of a very low calorie formula diet (VLCD), rapid weight loss leads to rapid remission of type 2 diabetes. A one-year study showed that BMI of obese diabetic patients was reduced by 5kg/m2 and that patients were able to discontinue insulin and oral hypoglycaemic agents for the whole year.2 A five-year follow-up study confirmed that VLCD treatment was safe and effective in overweight diabetic subjects. It has also been shown that normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes is achieved byVLCD dietary energy restriction.

 

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PHARMACIES LEAD THE WAY IN OBESITY MANAGEMENT

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

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

1-6aAdvantages of weight loss
There is certainly plenty of justification for helping overweight patients. Weight loss can lower blood pressure, normalise blood lipids, practically eliminate type 2 diabetes, reduce the severity of asthma, bring relief to arthritics, increase the fertility of women hoping for pregnancy, relieve sleep apnoea, and provide an opportunity for patients to be considered for Pharmacists can play an important role in weight management. And there’s evidence to support their effectiveness. elective surgery. Loss of weight can decrease the need for antidepressants, make exercise more possible – thus improving cardiovascular health, and can vastly improve the quality of life for patients. Methods of treatment, however, are not universally agreed upon. Somewhat unsurprisingly, bariatric surgeons tend to favour the surgical approach to weight loss. According to the Department of Bariatric Surgery at Imperial College, the current burden of morbid obesity in the UK is approximately 720,000 patients who meet NICE criteria for eligibility for surgery. In 2008 only 4,000 operations for morbid obesity were performed in the public and private sector combined. Even if the number of patients being treated by surgery was doubled, the impact on the problem would still be small and fall far short of the treatment needs of the seriously overweight population. Most surveys estimate that in the UK about 60 per cent of the population are overweight and about 30 per cent are already obese. Assuming a 60 million UK population, the number of people with a weight problem calculates to 36 million overweight and 18 million obese. Treating this many people surgically is unrealistic, to say the least. In addition, there is an increasing tendency for people to seek less expensive or more readily available bariatric surgery abroad, which has led to an ethical dilemma for NHS specialists. The costs to the NHS of providing aftercare, expected free by UK citizens, or emergency subsequent surgery when procedures initiated abroad go wrong, can be unplanned for and a substantial drain on NHS resources2.
Pharmacists’ role
Bariatric surgeons (in the current absence of a selection of effective weight loss drugs) are increasingly attempting to convince the public and the professionals that surgery is the only method of effectively treating seriously overweight people. The evidence presented by Mr McCaul clearly demonstrated that there is a non-invasive treatment that can be as effective. Like the claims for remission of diabetes as a result of the surgery, diabetes remissions are obtained by pharmacists as well since it is the loss of weight that leads to the remission. Usually, the blood sugar control is so rapid that it has become mandatory to get the doctor’s cooperation in stopping oral hypoglycaemic medications prior to the patient dieting. Without this step, patients are not permitted to participate in the Lipotrim programme. The results presented for this difficult cohort of morbidly obese patients was suitably impressive. These were very large individuals indeed, with half presenting with a BMI above 45 – the heaviest just below BMI 70. From this subset of 267 patients, the results reported were:

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

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

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

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

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

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MANAGING OBESITY BY CHALLENGING ADDICTION

Obesity has been linked to addiction.

What does this mean for the future of weight management?

Weight loss by total food replacement (the elimination of all food from the diet) is seen by some as a draconian and unnecessary approach to the management of obesity. When trying to devise a successful weight loss programme, the optimum approach would appear to be fairly straightforward simply reduce the daily caloric intake to a point below the level of calorie utilisation. In layman’s terms. just eat less. Indeed, there are many different approaches currently available, all based around the notion of eating less: low carb, low fat, calorie counting, behaviour modification (smaller plates) etc, not to mention the plethora of meal replacement programmes in which a small amount of non-formula foods may be consumed. Why then, would anyone need to use a total food replacement formula (very low calorie diet) in order to lose weight?

It is true that each of the available approaches to calorie restriction can have successful outcomes, even in cases where the logic of a diet plan is spurious or medically dubious, or possibly even in violation of the laws of thermodynamics. Whatever the given approach of a specific diet plan might be, it will Lead to weight loss if it reduces a dieter’s daily calorie intake to a point below the body’s daily requirement.

Unfortunately, nothing in life is ever that simple. Despite a bewildering selection of diet programmes, self-help books, drugs, even surgical interventions, the increase in overweight and obesity continues almost unabated. Weight regain is virtually universal regardless of the method of weight loss or the will of the dieter. Even post-surgical weight regain remains one of the bewildering frustrations of the field. The consequences of relentless gain of weight, however, in terms of medical co-morbidities, healthcare costs and personal quality of Life, make it necessary to find answers.

Obesity and addiction

The solution to obesity should be trivial, as we have already seen. All dieters have to do is just eat Less.

In addition, many people can and do control their eating behaviour and never appear to be in danger of escalation into obesity.

For those who do become obese however, their food behaviour often displays the compulsions and cravings of an addiction. Indeed, it is when food consumption is put into the context of other addictive behaviours that the nature of the problem becomes clear. The link between addiction and obesity 15 even being exploited in the search for drugs to combat obesity, as can be seen in the 30 July 2010 report in The Lancet on the use of naitrexone in conjunction with bupropion as a weight loss treatment.

How robust is the parallel between drug addiction and obesity, and are there insights from the research into addiction that can guide our treatment of overweight? Not all people who are exposed to habit-forming drugs become addicted, just as not all people exposed to high-fat, high-calorie foods become obese. Vast numbers of people consume moderate amounts of alcohol and do not advance to alcoholism. Many people are able to stop smoking as they take on board the health consequences of continuing.

Drugs and food appear to activate common reward circuitry in the brain. The brain naturally produces opiates: drug-like chemicals that cause pleasure sensations and are linked to addictions. Animal studies show that these chemicals can be a trigger for sweet, fatty cravings. And consuming such foods make the brain produce even more of the chemicals (as shown, for example, in studies of rats fed chocolate milk). When the brain’s normal opiate production was blocked, rats chose their normal feed over previously tempting sweets.

Drewnowski tested this approach on 41 women (bingers and normal eaters). They were offered their favourite foods. from pretzels and jelly beans to chocolate chip cookies and chocolate ice cream. Half received injections of naloxone, a drug used to treat heroin overdose because it blocks brain opiate receptors. The rest were given a placebo of saline.

Naloxone made the bingers eat considerably less – 160 fewer calories per meal, as Drewlowski reported in the American journal of C!nicol Nutrition. Their chocolate consumption dropped in favour of lower fat foods like popcorn. When asked to rate their favourite foods again, chocolate was rated lower than before. Significantly however, the non-bingers weren’t affected, a finding that might limit the widespread efficacy of the drug combination referred to above. If a person’s obesity is related to compulsive behaviour then this research is very encouraging. For others, however, its effectiveness will be extremely limited. In other words, it may only help those patients it can help.

If we accept a component of addiction in food abuse and ultimately obesity, then we need to recognise that the most powerful long term treatment for addictions is complete abstinence from the addictive substance. A reformed smoker is someone who does not smoke. A reformed alcoholic is someone who does not drink.

Alcoholics note that it is easier to draw a line between zero drinks and one drink, than between the first and second or even the sixth and seventh. There is an exact parallel with seriously overweight people: the introduction of almost any food can trigger the need for substantial food consumption. Unfortunately for the overweight, total abstinence from food is generally not considered feasible or even survivable. As a result, this most powerful tool for the control of food abuse is usually overlooked.

From a biological point of view, however, it is important to recognise that the human body does not survive on food, it Survives on nutrition. We require a constant supply of a very specific list of chemicals (nutrients) to sustain ourselves. These chemicals are typically ingested in the food we eat. Because there is no single food that exactly matches the nutritional needs of a human being, it is important that we receive our nutrition from a diverse range of foods. For an addict who abuses food, this presents a serious problem one that the mantra ‘just eat less’ completely fails to address.

Total food replacement programmes

The advantage of a total food replacement programme is that nutrition is provided by an engineered formula that is nutritionally complete. allowing the dieter to remove the addictive substance (food) from his of her fife while the weight is lost. The value of a total food replacement formula programme in the treatment of overweight and obesity should now be obvious. Total food replacement is the only means by which those who are subject to food abuse may avoid the addictive stimulus that perpetuates their weight problem.

This begs the question of how to proceed once the excess weight has been lost. Although the smoker should not return to cigarettes, and the alcoholic should not begin drinking again, the idea of avoiding traditional foods for life is a disturbing prospect, and one that no one would actually promote. The concept of permanently denying the pleasures of the table is unlikely even for the most food-averted of the population: itis inconceivable for the food addicted. There will inevitably be a food future, with the possibility (even probability) of weight regain. The availability of total food replacement formulas for future weight correction is likely the factor that protects against addiction transfer, an overwhelming and destructive consequence of weight reduction surgery.

Addiction transfer is a worrying and increasingly reported after-effect of bariatric surgery, as the loss of weight apparently does nothing to alleviate the addictive behaviour. Up to BO per cent of post surgical patients are reported to be transferring their addiction to other quarters (alcohol, gambling, promiscuous behaviour etc) to the point of self destruction. Addiction transfer appears to have a neurological basis, as research suggests that the same biochemical processes are at work in multiple types of impulse-control disorders. Each seems to trigger the same reward sites in the brain, resulting in cravings that are difficult to resist.

Weight loss with very low calorie diets has a clear advantage. When used strictly. ketogenic total food replacement diets are not perceived by the body as a deprivation condition requiring an alternative pleasurable stimulus which can lead to addiction transfer. Once in ‘ketosis’, a high percentage of patients report a mild euphoria or at least a sense of comfort and well being. VLCDs are rapidly being recognised as perhaps the only weight loss method that engenders the many health benefits of weight 1055 and crucially leaves the patient physically and psychologically healthy afterwards.

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FOR WANT OF A PLACEBO

…the strongest evidence for therapeutic interventions is provided by systematic review of randomized, double-blind, placebo-controlled trials involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, difficulties in ascertaining who is an expert, and more.

Wikipedia

Stephen Kreitman Ph.D. R.NJutr. (UK Registered Nutritionist) and Valerie Beeson Howard Foundation Research Ltd, Cambridge UK.

The Wikipedia quote above is one of countless examples that show the almost universal acceptance of this principle. There are, however, serious implications when the criteria for “evidence’ are defined in a manner that excludes other forms of valid evidence. A cliche catchphrase can become a cloak of invisibility. The idea of evidence based medicine would seem to be fairly uncontroversial, and indeed guides the actions of the UK healthcare community. After all, if there is no proof of efficacy, there is no justification for the use of a given treatment.

The classic randomised. double blind, placebo controlled trial is undoubtedly a powerful tool in the development of therapeutic treatments and procedures in the world of healthcare. The placebo effect is a well-known and unquestioned factor in the assessment of any potential treatment, andit is therefore logical to defer to any study that works to eliminate this effect. For this reason, all respected medical journals, most of the healthcare community, and certainly the government regulators require studies to meet these criteria before a treatment will even be considered.

Unfortunately, there are drawbacks. The most immediate difficulty with the classic notion of evidence based research is that some situations do not lend themselves well (or at all) to placebo controlled, double blind studies. In such cases, valuable information may be filtered out by the qualifiers set during literature searches and that information will never be seen by the very community that stands to benefit.

As a case in point, one of the more serious current healthcare problems is the rapid proliferation of type 2 diabetes. Current estimated costs to the NHS for treatment of this problem are a staggering E1 million per hour. However, a weight loss approach is available that costs the NHS nothing. can usually normalise blood sugars within a few days (even in long standing diabetes) and in most cases actually put type 2 diabetes into remission. This important clinical knowledge is virtually unknown because in this instance, it is impossible to design a placebo controlled study. Even thorough research of existing literature will be futile, since the information will usually be filtered out and not available for consideration.

Type 2 diabetes is usually a consequence of excess weight and it has been recognised for decades that weight loss will improve the clinical condition. In recent years, bariatric surgeons have become bolder with their own assertions and many now claim to ‘cure’ diabetes or at least put the disease into remission. It is certainly true that the weight loss associated with bariatric surgery can indeed put diabetes into remission, but the secondary claim – that surgery is the only means of accomplishing this – cannot be supported. If however, evidence of alternative means of substantial weight loss are filtered out and never even considered. bariatric surgery (by default) becomes the method of choice.

Shifting the balance of evidence

While case studies are often considered to be a lesser level of evidence, the balance of believable evidence must shift, especially when the number of cases being audited becomes virtually the entire treatment population. For the past 25 years GPs and pharmacists have been treating overweight and obese patients with very low calorie diets and monitoringtheir progress weekly over the course of their treatment. Those medical details and weekly progress reports have all been recorded, and a number of audits from individual GP practices and a 25 practice meta-audit have been published. As it is impossible to provide a placebo control for a VLCD, these results have been Largely unrecognised.

As the population of GP practices and pharmacies managing weight with VLCD has expanded and computer records become more available, it has become theoretically possible to audit the entire population. An audit from a group of pharmacies in the Republic of Ireland has provided data for over 9,000 Lipotrim patients. A single pharmacy in Prestwich. Manchester has provided audit data for over 1.100 dieting patients. Since these patients are seen weekly and their progress recorded by the health professionals, the information should be viewed as highly credible. The weight losses are having the same effect on type 2 diabetes as that reported for surgery. Patients, therefore, are not permitted to start the diet unless the GP has stopped diabetic medication. Blood sugars will normalise within a few days, and with a few weeks weight loss it is unlikely that any further diabetic medication will be required as long as they maintain some of the weight loss.

The key to the safety and efficacy of weight loss with VLCDs is the knowledgeable screening and continued monitoring by well trained health professionals. The extension of the medical programme as a pharmacy service has proven invaluable since pharmacy offers many advantages over GP treatment for a substantial number of reasons, not the least of which are accessibility and the availability for continued support long after the weight is lost.

The benefits of weight loss

NICE guidelines acknowledge extended use of VLCDs when properly monitored by healthcare professionals. There is certainly plenty of justification for helping overweight patients: weight loss can Lower blood pressure. normalise blood lipids, practically eliminate type 2 diabetes, reduce the severity of asthma, bring relief to arthritics, increase fertility, relieve sleep apnoea, provide an opportunity for patients to be considered for elective surgery, decrease the need for antidepressants, make exercise more possible – thus improving cardiovascular health and vastly improve the quality of life for patients.

There is now a 30 year history of safe and effective worldwide usage of total food replacements based upon the concept of low fat nutrient-complete enteral feeds (VLCDs as they came to be known). An enormous volume of scientific and medical literature has been thoroughly evaluated by expert committees and they have been recognised as safe and, in cases such as type 2 diabetes, more effective than standard weight loss methods. An expanding network of health professionals in UK and Irish pharmacies are now offering a range of treatments for weight problems. They have the training, the respect of the public, the contact hours and the desire to offer weight management as an expanded professional service. NICE recommends that specialists be used: these trained and experienced pharmacists and GPs are achieving considerable success and their success should not remain invisible for want of a suitable placebo.

“The current burden of morbid obesity in the UK is approximately 720,000 patients who meet NICE criteria for eligibility for surgery. Lost year, only 4,000 operations for morbid obesity were performed in the public and private sector combined.”‘

Even if the number of patients being treated by surgery was doubled, the impact on the problem would still be small. Doubling the costs of the surgery and aftercare would raise the percentage from a paltry 0.5 per cent to a marginally Less paltry 1.1 per cent_ This is still far short of the treatment needs of the seriously overweight population. Most surveys now estimate that 60 per cent of the UK population is overweight and about 30 per cent already obese. Assuming a total population of 60 million in the UK the number of people with a weight problem calculates to 36 million overweight and 18 million obese. In the audit from the Irish pharmacies mentioned earlier, 7,259 people lost more than 5 per cent of their prediet weight. 2.969 lost more than 10 per cent. In the Prestwich pharmacy, 94 per cent lost more than 5 per cent of their prediet vveight, 47 per cent lost more than 10 per cent and. 21 per cent of the patients lost more than 20 per cent.

Obviously, something more readily available than just surgery is needed, not only for treatment but also to prevent the progression from overweight to obesity to the massive obesity that passes the threshold for surgical intervention. Such methods are already available and would be more widely recognised if the usual search limits for evidence based treatments were modified to accept other perfectly valid forms of evidence. In

Reference

1. Thc Provision of Bariatric Surgery in the United Kingdom! Past, Present and Future Considerations: The Road to Excellence. Department of Bariatric Surgery, Imperial College Healthcare, Charing Cross Hospital, London, September, 2009.

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