Tag Archives: cessation of food intake


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

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.5 These pharmacists are trained and experienced specialists in the use of VLCD. Suggest a pharmacist to offer your patients real help with their excess weight. This will even reverse the ever increasing prevalence of type 2 diabetes.


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


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.


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 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.


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.


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.


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.


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.


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




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.


PDF Version: 2-2-napc_2012-maintenance