Vending machines for prescription drugs are already here. How much longer will you be here?If you intend to be a pharmacist of tomorrow, you need to start acting today. Delivering a professional weight management service is a good place to start
THE ROYAL PHARMACEUTICAL SOCIETY has set out best practice standards for pharmacies delivering public health services in England and Wales. The ‘Professional standards for public health practice for pharmacy’ were created in partnership with the Department of Health, Royal Society for Public Health and Faculty of Public Health, and focus strongly on backing up services with data. They call on pharmacists to ensure their public health offering is evidence-based, tailoring it to local needs wherever possible, and to gather data that proves the value of services
Of all the important services being offered in pharmacy, it could be argued that weight management is the most valuable and documentable. It is valuable because controlling weight prevents and can even treat type 2 diabetes, high blood pressure, depression, sleep apnoea, poor fertility and a host of other health issues that are prevalent in the community. It can even impact on services such as smoking cessation, since the possibility of weight gain is often a reason for failure to stop smoking.
A weight management service is readily documentable, since tracker software is available that will instantly provide evidence for weight loss achievements and medical benefits from the weight loss. If you can’t produce data, you have no proof of your pharmacy’s accomplishments.
Treating overweight, but not-yet-obese, people in pharmacy, is obesity prevention on the high street. There are over 30 million overweight and obese people in the United Kingdom. Since no one ever became obese without first being overweight, it is important to provide real help to people at this stage. It is much less problematic to help people who do not have a massive amount of weight to lose and who also do not yet have some of the serious medical consequences associated with excess weight.
Pharmacy has become the prime location for weight management in the UK and Ireland. With the NHS ‘Call to Action’, pharmacy professional bodies are urging pharmacists to make their voices heard and shout about the good they do in improving people’s health.
Helping people lose weight is not just about making them feel good but is also about preventing major long-term health problems, such as type 2 diabetes. A recent article in GP magazine reported a staggering seven-fold rise in insulin use in type 2 diabetes over a nine-year period. An effective pharmacy weight management service could have an enormous and immediate benefit.
But it seems that it’s not just the NHS that needs to hear what pharmacy has to say. The public do, too. North London LPC was inundated with enquiries about a newsletter it had produced raising awareness of pharmacy services in the area.
Promote your service
So what does that mean to you as a pharmacist with a team already offering an established weight management service? Promote your service far and wide and show the public and the NHS what you’ve been doing to improve the health of the nation.
Fin McCaul, for example, is first and foremost a community pharmacist practising in Manchester. He is also the chairman of the Independent Pharmacy Federation and works for Bury CCG one day a week as its long-term conditions lead.
Fin’s passion for independent pharmacy is second only to helping patients lose weight and stop smoking. With an average of 100 quits per year and well over 1,000 patients helped through the weight loss service in his pharmacy, there is nobody better placed to talk about the opportunities and challenges for pharmacy now that public health commissioning has moved into the care of local authorities.
Delegation, motivation and marketing skills and advice for pharmacists and their team are just some of the benefits from his stop smoking/weight loss clinics. At the 2013 Pharmacy Show Mr McCaul organised a series of patient services workshops delivered by pharmacists who were successfully running weight services in their local community and wanted to share their knowledge and expertise. At the March 2014 Independent Pharmacy Federation conference, Fin again provided the opportunity for training in critical pharmacy services and the weight management clinic run by author Valerie Beeson was well attended and appreciated.
A giant change in practice
NHS England’s education arm has launched new standards for pharmacists delivering patient consultations, which have been hailed as a “giant change” in pharmacy practice. Health Education England (HEE) called on pharmacists to ensure they were educating patients, building a relationship with them and respecting their individual needs when conducting consultations.
The Westminster Food and Nutrition Forum seminar, held in London in February, kicked off with the staggering statistic that more than half of the UK population could be obese before 2050. This could create costs of £50 billion a year to the NHS, warned speakers, who included representatives from NHS England, Public Health England, NICE, the Department of Health, CCGs and the nutrition sector.
The speakers agreed that primary care is the key battleground for tackling the issue. But with GPs and pharmacists at the frontline of delivering public health services, who is better placed to keep the nation’s waistline under control? It is clearly pharmacy.
There was no doubt that pharmacy should offer obesity services. Ash Soni, pharmacist and vice chair of the RPS English Pharmacy Board argued that most overweight people did not feel unwell so would usually fail to see the point of visiting their GP. Mr Soni believed using a medical model was the wrong starting point. Most people visited pharmacies for multiple reasons, which presented an “ideal opportunity.”
Pharmacy is an excellent provider of weight services for the community. Many overweight people in the BMI 25-30 range take advantage of pharmacy weight loss programmes, recognising that they really work and feeling confident that they are being monitored by healthcare professionals. Pharmacists’ expertise in weight management, however, has proven extremely valuable for the treatment of obese and even morbidly obese people. This is a group who could have qualified for bariatric surgery at great expense and risk.
Effective weight loss absolutely needs to be monitored by knowledgeable healthcare professionals, because real weight loss is not benign. Type 2 diabetics, for example, who lose weight by compliance with a total food replacement diet programme, will induce remission of their diabetes within a few days and continuing with hypoglycaemic medication can result in hypoglycaemia.
There are multitudes of patients taking drugs with a very narrow safety spectrum, such as warfarin or lithium. Dieting can alter the absorption of these drugs, so dosages need to be carefully monitored. There are some people who really should not be dieting at all. Pregnant women, patients with a recent history of surgery, stroke or heart attack are not logical candidates for weight loss.
Weight maintenance requires attention and is not usually possible in a busy medical practice. Long-term support in a pharmacy increases the weight maintenance prognosis for dieters.
Now or never
According the the Royal Pharmaceutical Society, it is ‘Now or Never’. “Pharmacists need to become first and foremost providers of patient care, rather than dispensers and suppliers of medicines This is central to securing a future in which the profession can flourish,” it says.
To be a ‘Today’s Pharmacist’ and have your pharmacy remain a valued destination on the high street, start developing and promoting your one-on-one services now. For patients to recognise and value your services, use your consultation room for patient services and not storage space. Be properly equipped for a weight management service by having weighing scales comparable to the ones we provide, that can weigh patients up to 32 stone. Have a chair in the consulting room with no arms that is strong enough to support an obese patient. Be professional, knowledgable, understanding and effective with your weight service.
The pharmacists of tomorrow will have a much greater opportunity to make use of their extensive pharmacy education, long after the vending machines have dominated the prescription business.
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The Healthy Living Pharmacy initiative has far exceeded expectations, now having nearly 200 accredited HLPs in 20 pathfinder sites across 30 PCTs, with many more vying to get involved. In the meantime, the government’s Pharmacy and Public Health Forum chair Professor Richard Parish has told community pharmacy that ‘its time has come’ and urged it to capitalise on the opportunities out there.
Pharmacy has not had a bigger opportunity than this to make its mark in public health. HLP aims to improve the health and wellbeing of the local community through high quality pharmacy-delivered public health services, including weight management. The pathfinder sites’ remit will also be to build the evidence-base for pharmacy’s contribution to public health
Lipotrim has been behind pharmacy’s public health role all along, developing its weight management service package to enhance pharmacy’s developing professional roles. And since introducing the service from the GP arena to pharmacy over 10 years
ago, Lipotrim now has more than 2000 pharmacies offering the service, this represents a strong body of evidence to support pharmacy’s role in weight loss.
Foreseeing the value of evidence, the company has also developed the Lipotrim Pharmacy Patient Tracker to make it easy for each pharmacy to audit its own service and demonstrate value. For anyone looking to get involved in HLPs and use it to drive
their weight management service, this will be an invaluable tool.
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Interest in the use of weight loss to treat type 2 diabetes has been intensifying in recent years, despite the fact that the rapid therapeutic effect of weight loss on type 2 diabetes has been
well documented for decades and has been hitherto largely ignored. The current interest may be attributed in large part to a number of publications generated by evidence (from bariatric surgery) of the almost universal prompt remission of diabetes with weight loss after successful surgery.
One such study was published in the Journal of Endocrinology and Metabolism in 2004 by Cummings et al – ‘Gastric Bypass for Obesity:
Mechanisms of Weight Loss and Diabetes Remission’. In support of their efforts to promote the use of surgical techniques, the authors claimed that no more than 5-10 per cent of body weight can be lost through dieting, exercise or the few available anti-obesity medications. They further write, correctly, that: “Importantly, even mild weight loss confers disproportionate health benefits, in terms of ameliorating obesity-related comorbidities. Nevertheless more substantial and durable weight reduction would improve these ailments more effectively.”
And not correctly that:
“At present, bariatric surgery is the most effective method to achieve major weight loss. The best operations reduce body weight by 35-40 per cent.”
Quite a dramatic claim, but surgery is not the only effective means of achieving this amount of weight loss when necessary.
The very low Calorie diet
There is a readily available alternative to bariatric surgery, without the problematic aspects of bariatric surgery:
high morbidity and mortality risk, prohibitively high cost, possible post-operative addiction transfer and (in consideration of the large numbers of severely overweight people with or without diabetes) extremely limited availability. This alternative is the very low Calorie diet.
Detailed records have been kept of the weight loss results from GP practices and pharmacies. Using audit data, accumulated from UK pharmacies, it was possible to document cases where
dieters successfully lost in excess of 35 per cent of their pre-diet weight. These pharmacy weight loss programmes are based upon a replacement of all normal foods with a nutrient complete formula. There are many advantages to this approach over bariatric surgery, especially with severely overweight people. There is now an expanding literature – based upon numerous investigations into addiction – which demonstrate that in a considerable percentage of high BMI people, the same metabolic pathways that are generally recognised as part of the addiction profile are shared by people who are using food as a substance of abuse. In the case of every known addiction it is absolutely necessary to completely stop the abused substance. This is difficult when the substance in question is alcohol, tobacco or drugs; it is literally unachievable when the addictive substance is food, which is required in order to stay alive. While ultimately food is required for energy, there is no shortage of energy stored as fat and glycogen in overweight people. What must be supplied in order to keep people healthy are the vitamins, minerals, trace elements, essential amino acids and essential fatty acids. Depletion of any of these nutrients will compromise health. Post bariatric surgery patients are expected to reintroduce foods in limited quantities. In contrast, use of a nutrient complete formula provides all the essential nutrients in the absolute minimum number of Calories. This allows weight loss at the maximum safe rate, while allowing the person to completely stop eating the foods that they are abusing. This is the only approach that will interfere with the addictive problem and offer a reasonable chance of establishing a normal relationship with food in the future.
Counting the Calories
There is yet another important benefit to using a foodreplacement formula instead of traditional foods. Traditional foods are derived from various plants and animals and naturally differ in nutrient composition and Calorie contribution, so it is not possible to get an accurate estimate of the energy intake. Food composition tables (which present averages from a large number of samples) can differ widely from the composition of a specific sample. In contrast, the Caloric composition of a defined formula can be known with considerable precision. Dieters therefore can know exactly the number of Calories they are eating each day. It is well known that the Calorie deficit required to lose a pound of body fat is fixed at 3,500. The difference between the Calories in the formula and the Calories used by the individual based upon genetics and lifestyle will represent the rate at which the 3500 Calories is being depleted. Calorie utilisation for most people, especially severely overweight people who are not usually involved in massive exercise programmes, does not vary a great deal from day to day. Variations are trivial when it is realised that running a mile only consumes an additional 100 Calories, so the number of Calories used each day is basically constant. This explains the essentially straight line pattern of weight loss with VLCD. From the daily changes in weight, it is easy to determine the number of Calories used by each individual day after day. This then will inform the individual of the critical Calorie intake that will determine whether weight is gained, lost or maintained. There is no other method to gain this information under real life conditions. Cummings et al, in the paper cited above, provide estimates of the cost of bariatric surgery (2004 data) represented as QALY (quality adjusted life years), ranging from 5,400 to $36,300, which they state is well under the $50,000 generally regarded in the United States as being cost effective. It might be worth considering a VLCD pharmacy programme
which will routinely provide weight losses of one stone (6.3 kg) a month for women and one and a half stone (10 kg) for men. And unlike bariatric surgery, the programmes can be used with people who have far less weight to lose than the BMI 35-40 subjects reported here. These programmes are even suitable for obesity prevention in overweight (but not yet obese) individuals who fall into the range of BMI 25-30. This is a far more appropriate contribution to public health and prevention of diabetes.
Weight loss and type 2 diabetes
Type 2 diabetes is a disease of excess weight. There are countless thousands of papers in the literature that concur with this statement. It would seem to be obvious therefore that treatment protocols should focus on rapid and effective weight loss for patients with diabetes. If one thinks ‘diabetes is excess weight’, one would be right most of the time.
Conventional weight loss options have generally proven so unreliable that it is understandable and (almost) forgivable that weight loss is not vigorously promoted for treatment of
type 2 diabetes. Nevertheless, there is a much better option than bariatric surgery for weight loss. Worldwide research spanning a period approaching 40 years has repeatedly
demonstrated that sufficient weight loss to treat diabetes can be achieved, and indeed is currently being achieved in the UK and Ireland by a large number of pharmacists.
Furthermore, fully established diabetes is only part of the problem (even though the UK is reported to be spending about £9 billion a year dealing with diabetes).
There is also a well recognised pre-diabetes syndrome with resistance to insulin, hypertension and elevated blood sugar and lipids, the so-called syndrome X. The best recognised treatment is also, of course, weight loss. A very detailed meta-analysis and review of co-morbidities related to obesity and overweight from British Columbia, published in 2009, identified 18 co-morbidities contributing, according to the authors, to a very large future disease burden as weight continues to be a medical problem. Pharmacists deserve considerable recognition for providing a service for remission of diabetes and relief of co-morbidities, where present, without depleting the assets of the National Health Service.
And, crucially, praise for the effective treatment of excess weight in hundreds of thousands of documented patients.
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Audit Results using the Lipotrim Patient Tracker
by Gareth Evans
The current excitement generated by the press coverage of the Newcastle University study of diabetic patients using weight loss by a very low calorie diet to “cure” diabetes, necessitates a wider recognition of the well established programmes already available. The Lipotrim weight loss programme, monitored exclusively by healthcare professionals has been in extensive use in the UK for more than 25 years. A rapidly expanding network of nearly 2000 pharmacies currently offer the VLCD service and although many have used manual methods to audit their patients’ achievements, the newly provided Patient Tracker computer software for managing patient records has permitted continuous auditing of results and detailed evaluation of population subsets.
For example, in addition to auditing the total experience of patients enrolled in the pharmacist-run service, the results can be examined in many different ways. The cohort can be divided by gender, by age, by initial or final BMI, by amount or percentage of weight loss achieved, or by medical history (hypertension, diabetes, depression, thyroid problems etc.). The programme extends beyond weight loss, as there is a refeeding transition back to ordinary foods and a full maintenance programme, which is proving extremely successful in the pharmacy environment. With this Tracker audit tool, therefore, evidence is also available documenting the long term maintenance outcome after dieting.
As a pharmacist who has been using the Tracker to keep my Lipotrim patients’ records for some time now, I would like to share a current audit of my patients’.
Materials and Methods
Overweight or obese people requesting the programme are assessed for suitability on the basis of initial BMI and a detailed medical history. Those requiring medical cooperation, such as those with type 2 diabetes or medicated hypertension make suitable arrangements with their GP prior to dieting or are excluded. Those with contraindicated conditions, such as insulin dependant diabetes or pregnancy are excluded from the programme.
Suitable candidates follow a strict regime of total food replacement using nutrient complete formulas, essentially very low fat enteral feeds, with adequate fluid intake and only black tea or coffee permitted in addition. Appropriate prescribed medications are continued as well. No other foods, beverages or supplements are permitted.
Dieters are monitored and weights recorded weekly – only 1 week’s supply of formulas can be obtained at each visit and obvious non-compliance is corrected or the dieter is offered alternative weight loss advice.
Records are maintained on the Patient Tracker programme.
Total Population of Dieters completing 3 or more weeks on Total Food Replacement
Mean Start Weight 91 kg – Mean End Weight 81 kg
Total weight lost to date of audit – 3865 kg
Table 1 N= 382 330 Females 52 Males
|Mean||Start wt||91kg||Start BMI||32.7||End BMI||29.0||% wt loss||10.8|
|Median||Start wt||88.2 kg||Start BMI||32.0||End BMI||28.4||% wt loss||9.0|
The next series of tables demonstrates the value of the Lipotrim service in overweight patients, reducing the likelihood of their progression to obesity, as well as obese, super obese, morbid obese or even super-morbid obese patients.
Table 2 N= 121 BMI 25-30
|Mean||Start BMI||28.1||End BMI||25.4||% wt loss||9.3|
|Median||Start BMI||28.3||End BMI||25.4||% wt loss||8.0|
Table 3 N= 141 BMI 30-35
|Mean||Start BMI||32.4||End BMI||28.9||% wt loss||10.9|
|Median||Start BMI||32.3||End BMI||29.1||% wt loss||12.0|
Table 4 N= 73 BMI 35-40
|Mean||Start BMI||36.9||End BMI||32.4||% wt loss||12.9|
|Median||Start BMI||36.7||End BMI||32.6||% wt loss||11.0|
Table 5 N= 29 BMI 40-45
|Mean||Start BMI||42.2||End BMI||36.1||% wt loss||14.4|
|Median||Start BMI||42.0||End BMI||36.3||% wt loss||11.0|
Table 6 N= 5 BMI 45-50
|Mean||Start BMI||47.4||End BMI||37.2||% wt loss||21.2|
|Median||Start BMI||47.3||End BMI||36.9||% wt loss||22.0|
Other subsets of the patient information that are of interest include:
Table 7: Obese people who exceeded the 5% criterion for medical benefit of weight loss.
Tables 8and 8a: Some dieters choose to interrupt their diet for varied reasons and then return for a subsequent diet period. Their first and second dieting courses can be examined separately.
Table 9: After a period of weight loss, it is necessary to re-introduce carbohydrates in a controlled manner to minimise weight regain due to carbohydrate loading. Minimal weight change is expected despite reintroduction of normal foods. This phase is 1 week long.
Table 10: The Tracker software distinguishes between periods of dieting and maintenance providing evidence of minimal recidivism when patients are properly supported in the pharmacy environment.
Table 7 N= 231 BMI > 30 who lost 5% or more of initial weight
|Mean||Start BMI||35.3||End BMI||30.8||% wt loss||12.7|
|Median||Start BMI||34.5||End BMI||30.1||% wt loss||11.0|
Table 8 N= 78 Dieters who had 2 dieting courses First time
|Mean||Start BMI||32.1||End BMI||29.1||% wt loss||9.0|
|Median||Start BMI||31.2||End BMI||28||% wt loss||7.5|
Table 8a N= 78 Dieters who had 2 dieting courses Second time
|Mean||Start BMI||31.1||End BMI||29.6||% wt loss||4.7|
|Median||Start BMI||29.7||End BMI||28.1||% wt loss||3.5|
Table 9 N= 140 Refeeding week
|Mean||Start BMI||27.5||End BMI||27.4||% wt loss||-.2|
|Median||Start BMI||26.6||End BMI||26.6||% wt loss||0|
Table 10 N= 249 Maintenance after dieting
|Mean||Start BMI||28.1||End BMI||28.1||% wt loss||0.1|
|Median||Start BMI||27.2||End BMI||27.0||% wt loss||0|
Patients who are medicated for various weight related ailments can often be considered as different categories of patient. Many hypothyroid patients have experienced great difficulty with weight management. Depression and hypertension often have a weight component in the aetiology of the problem.
Table 11: Examines patients on medication for hypertension
Table 12: Examines patients on medication for hypothroidism
Table 13: Examines patients on medication for Depression
Table 11 N= 22 Patients with High Blood Pressure
|Mean||Start BMI||36.2||End BMI||32.0||% wt loss||11.6|
|Median||Start BMI||37||End BMI||32.2||% wt loss||8.5|
Table 12 N= 9 Patients with thyroid hormone replacement
|Mean||Start BMI||34.5||End BMI||29.4||% wt loss||14.2|
|Median||Start BMI||34.7||End BMI||28.9||% wt loss||10.0|
Table 13 N= 13 Patients with Depression
|Mean||Start BMI||33.2||End BMI||28.2||% wt loss||13.0|
|Median||Start BMI||32.2||End BMI||28.9||% wt loss||11.0|
The extreme flexibility of the Patient Tracker software, in addition to documenting and visualising each individual patient’s experience, allows for presentation of evidence of the weight loss achievements of cohorts of patients. This has become important for commissioning and the new ability of grouping patients from an individual surgery permits certification to the surgery of the collective progress of their patients, These results can be of value for CPD as well.
As can be seen from the multiple tables presented as illustration, the percentage of initial weight lost generally averages well over 5% and in most cases over 10%. Even the median values, which documents the half-way values of the ranges, are generally very close to the mean. Successful weight loss is found even in the extremely high BMI patients, who are usually refractory to weight management attempts.
In addition to demonstrating the successful loss of weight by the dieters, regardless of the sub-category for grouping, it is important to note that even though there are some variations in patients’ experiences with re-feeding (Table 9) and follow on maintenance (Table 10), the overall lack of weight regain from the patients post-diet demonstrates the value of the pharmacist and the Lipotrim programme for long term weight control.
Despite the fact that these results reflect the efforts of a single pharmacist in a programme that currently lists nearly 2000 pharmacies throughout the UK and Ireland, it is important to have the tools that can satisfy the need for documentation of achievement in this era of evidence-based treatments. The success of this pharmacy service has considerably enhanced my professional satisfaction as a pharmacist.
…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.
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
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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