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.
Advantages 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.
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.
Total 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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