Tag Archives: rapid weight loss

Assuring there will be a ‘tomorrow’s pharmacist’

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

By Dr Stephen Kreitzman Ph.D, RNutr and Valerie Beeson, of Howard Foundation Researchp1

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.

The not-yet-obese
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.”

Effective weight managementp2

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.

p3

 

PDF Version: todayspharmacist

OBESE PATIENTS IN UK GENERAL PRACTICES LOSE 16 TONNES

S N Kreitzman PhD and V Beeson
(University of Cambridge, Howard Foundation Research, Cambridge, UK)

ABSTRACT
Objectives: To assess the weight losses and weight maintenance achieved with obese, often medically compromised, patients following a common Lipotrim treatment protocol.
Design: Data collation from voluntary responses by the practices to a general request for weight statistics, in a way that respects patient confidentiality. The sample of practices represents approximately 15% of those following the common protocol at the time of assessment.
Setting: 25 general practices and 2 hospital clinics in the UK.
Subjects: 818 obese patients registered with the practices or under medical referral to the hospital clinics The medical conditions ranged from apparently uncomplicated obesity to severely medically compromised patients, all treated under closely monitored conditions. Initial BMIs ranged from 24.4 to 78.7.
Interventions: Three, phased protocols, for weight loss, transitional refeeding and weight maintenance. Weight loss phase based upon Total Food Replacement under strict medical control – with specific, nutrient complete formula VLCD. Weight maintenance based upon modification of eating behaviour to significant dietary fat restriction. Considerable educational
materials provided throughout programme; approached conceptually as an addiction control problem.
Main outcome measures: Body weight and Body Mass Index at start of programme, at end of weight loss phase and the most recent follow-up available for each patient.
Results: Weight losses totalling in excess of 16,000kg with high levels of compliance and clinically encouraging weight maintenance results.
Conclusions: Obesity can be managed effectively under a variety of practice conditions, even in ‘heart sink’ patients who have repeatedly failed in the past to control their weight, despite the best efforts of the clinical team.

INTRODUCTION
Despite the prevalent academic knowledge of the medical problems associated with obesity (1-13), the frequent failure to achieve weight loss in obese patients has discouraged many practitioners from using weight loss as a primary treatment (2,18). Unless obesity is tackled, however, the scenario of a possible 25% of the population being obese by the year 2005 instead of the Health of the Nation target levels of 6 to 8 percent as in 1990 (14,15), will continue to be a health care frustration.

The impact of effective obesity treatment in general practice, however, is very dramatic. When patients with type II diabetes lose significant weight quickly, glycaemic control is improved better than the same weight loss achieved more slowly, and this appears robust even in patients where some weight is regained (7, 9, 10, 11, 16, 17).

In non insulin dependent diabetes mellitus (NIDDM), hypoglycaemic agents are generally stopped within a week or two (9). An impressive percentage of patients with hypertension have
also been able to reduce dosage or totally eliminate medication, often after only modest weight loss (7,11).

The impact of such major health improvement sin patients with long-standing and progressive disease provides the momentum for practices to continue to devote effort and resources to obesity management (25).
This paper reports a META-AUDIT of weight loss and maintenance results from ongoing obesity management programmes in UK general medical practice sites and hospital clinics following a common treatment protocol.
Total weight lost by 818 patients was 16,211kg (16+ tonnes).

METHODS
Meta-Audit
Weight information relating to the obesity control programmes was obtained from 25 UK general practices and 2 hospital clinics. Patients were not identified to the investigators, except by a sequential code number at each site. The information provided from each location included height, initial weight and date, end of weight loss phase (refeed) weight and date, and the last recorded follow-up weight and date. About half of the patients were still in the weight loss phase of the protocol at the time of the audit. This posed analytical dilemma. It was decided to treat the weight of those still dieting at the date of audit as if it were a refeed weight with a maintenance time of zero. Only in the separate maintenance data analysis does the category of
refeed refer purely to those patients who have completed their weight loss phase and resumed conventional food for at least one month.

PROTOCOL
At each site, patients join the programme solely at the medical discretion of the doctor who is versed in the protocol. In accordance with NHS practice, there is no financial consideration to the practice, from any source. The role of the GP is primarily the medical selection of appropriate patients and the monitoring of prescribed medications, which often have to be reduced or stopped as a result of the weight loss.
Patients are seen weekly, usually by a designated and trained practice nurse. In rare cases, extremely medically fragile patients are dieted and these cases are generally seen regularly by the GP. In general practice, the GP orders the Lipotrim formula foods weekly by positive release using a Special Order. This assures that patients cannot obtain the diet from the chemist without the knowledge and approval of the GP who is properly informed about the Lipotrim programme (26-28).
The Lipotrim is a nutrient complete very low calorie diet (VLCD) formulation. The diet is purchased from a local Pharmacist. This is the patient’s only access to the diet. Control of access is totally under the GP’s authority. Patients are expected to comply with the rigid diet and maintenance protocols. These are explained in detail by written material, video and audio taped sessions. Interactive lecture sessions are provided for patients and staff. Most practices limit the number of patients treated at any one time. Available places are rapidly filled from a waiting list.


Results
The results demonstrate that significant (Table 1) and sustained (Table 2) improvement in the weight of obese patients can be achieved under varied medical practice conditions.


Individual practices were able to achieve a range of mean rates for weight loss in their patients (figure 1). The expected rate of weight loss for full compliance with the programme is an average of 1.46kg per week (1 stone per month). This was achieved.

MAINTENANCE
A subset of 414 patients, who had completed their weight loss phase at the time of audit and were attempting to maintained their weight, were evaluated.

MORBID OBESITY
The clinical options for very fat people are limited. Most GPs despair of treating the massively obese. The population in this audit compilation included 215 patients over BMI 40, 30 patients over BMI 50 and 7 patients over BMI 60. Results from these patients are documented in Table 3 A-C respectively. Many of these patients are still in the weight loss phase (see Table 3).

DISCUSSION
The widespread apathy apparent in the general medical reluctance to deal with the obesity problem stems from a long history of futile efforts. Whether this is related to the ineffective modes of treatment offered, a general lack of understanding by either the patient or health professional, or a combination of both, is not clear. The prevailing view has become ‘diets do not work’ (18, 27). This view needs to be altered to reflect the very real difference between dieting protocols. Some standard weight reduction diets can work for some overweight patients. Applying the same approaches to the obese, however, will frequently result in failure. Obese patients require a more decisive treatment protocol (28). Rates of weight loss achieved per practice were shown in Figure 1.

The premise that weight control is futile is unjustified and clinically insupportable when one considers that obesity itself is a risk factor for many serious clinical conditions (19). A large proportion of normal surgery time is spent dealing with many minor ailments, which are fundamentally weight related and which can escalate into serious disease when the weight problem reaches obesity (Body Mass Index >30) (20). Obesity occurring within a family unit can compromise the well being of that unit. The family ‘ill health’ is particularly problematic when the mother is obese. Depressive states and impaired quality of life (8) can affect a significant part of the patient’s daily routine and impact on the rest of the family members. A multiplicity of problems can be traced to obesity within the family.

Much is said about the need to educate and modify lifestyle (20), but the impact of dietary education is considerably grater when the patient is in a positive state of mind, with improved self esteem resulting from weight loss. Sedentary lifestyles are often a consequence of the excessive weight. With weight loss, most patients become significantly more active. This has been shown to increase the probability of maintenance of the lost weight (21).

For the obese, clinical weight goals may not necessarily be to achieve thinness. A more immediate goal may be to control elevated blood sugar or high blood pressure. It may be to allow
the patient access to certain surgical procedures, for blood lipid control or increased mobility or pain relief in an arthritic patient. Clinical judgement will require consideration of age, lifestyle and medical condition in setting realistic weight targets for an individual patient. The current ‘fashion figure’ is not the appropriate determinant of the weight target in the obese.

Weight regain needs to be put into perspective. The percentage of patients maintaining weight loss after medical obesity treatment far exceeds previous statistics (22). Long term weight maintenance at encouraging levels is now commonly reported for medical VLCD programmes (23,24), particularly when these include behavioural modification. There are no permanent cures for obesity. Despite this, an increasingly large number of patients can manage to maintain control for long periods after weight loss, albeit to varying degrees. A patient, however, who has lost 100kg and has regained 50kg is still 50kg lighter. This is particularly important where the lowered weight has allowed necessary surgery to be performed or improved another condition. The evidence of Wing, previously cited, and others (7, 11, 16, 17), suggests that some health benefits of weight loss (glycaemic control) can outlast the weight loss.

Dropout rates are important, but difficult to document. While the weight losses in this assessment are dramatic, no weight programme is universally successful. It is especially difficult to
assess the proportion of non-starters from the data available. The referral procedures into the programme vary widely from site to site. At some sites, access to the programmes is exclusively based upon the medical requirement for weight loss in an attempt to mitigate a pre-existing clinical condition. These referred patients are sometimes reluctant to comply or are disinterested in weight loss. In others, there is a component of self-referral, although the regulation of admission to the programme still remains entirely under the control of the practice. How many patients are referred to the programmes and decline participation cannot be estimated from the data available.
Also difficult to document accurately are the percentages of patients who attempt the protocol but find the initial days too difficult for their current level of motivation. Some practices
provided data from those patients who failed to attend beyond 1 week, but most did not.

Our analysis, therefore, includes all patients who participated for at least 2 weeks. The data demonstrates that established patients complete the course. Figure 2 depicts the fraction of the 818 patients who stopped dieting within monthly intervals.

In Figure 3, the mean BMI changes for the subset of patients whoceased dieting within those monthly checkpoints are presented. Patients conclude dieting for many and varied reasons, only one of which is non-compliance and failure. These failures are included in the 6 percent (51 patients) of patients who discontinued during the first 4 weeks of treatment. Patients stop when they have achieved clinical goals, as discussed previously. It is evident from this graph that patients, on average, continue their weight loss programmes until they are no longer obese, regardless of their BMI at the start.

References
National Task Force. Very Low Calorie diets. JAMA 1993, 270, 8, 967974.

West KM. Diet Therapy of Diabetes: An Analysis of Failure. Ann Intern Med 1973, 79, 425434.

Anderson J W, Hamilton C C, Brinkman Kaplan V. Benefits and Risks of an Intensive Very Low Calorie Diet Programme for Severe Obesity. Am J Gastroenterology 1992, 87, 1, 615.

Chiang B N, Perlman L V, Epstein L V. Overweight and Hypertension: A review. Circulation 1969, 39, 403421.

Maxwell M H, Heber D, Waks A U, Tuck M L. The Role of Insulin and Norepinephrine.

Kannel W B, brand N, Skinner J J, Dawber T R, McNamara P M. The Relation of Adiposity to Blood Pressure and Development of Hypertension: The Framingham Study. Ann Int Med 1967, 67, 1, 4859.

Wing R R. Use of very low calorie diets in the treatment of obese persons with non insulin dependent diabetes mellitus. J Am Dietetic Assoc 1995, 95, 5, 569572.

Sarlio Lahteenkorva S, Stunkard A, Rissanen A. Psychosocial Factors and quality of life in obesity. Int J Obesity 1995, 19, 6, S1S5.

Paisey R B, Harvey P, Rice S, Belka I, Bower L, Dunn M, Paisey R M, Frost J, Goldman P, Ash I. Short term results of an open trial of very low calorie diet or intensive conventional diet in type 2 diabetes. Practical Diabetes Internat 1995, 12, 6, 263267.

Kirschner M A, Schneider G, Ertel N H, Gorman J. An Eight Year Experience with a Very Low Calorie Formula Diet for Control of Mahor Obesity. Int J Obesity 1988, 12, 6980.

Wing R R, Greeno C G. Behavioural and psychosocial aspects of obesity and its treatment. Ballier’s Clinical Endocrinology and Metabolism 1994, 8, 3, 689703.

Office of Health Economics. Obesity 1994, 112.

Berg F F. Health risks of obesity. Obesity and Health 1993, 10-35.

The Health of the Nation. Department of Health. London HMSO, 1992.

The Health of the Nation. Health Survey for England 1991. Social Survey Division of OPCS. London HMSO, 1993.

Hernandez-Bayo J A, Herranz L, Megia A, Martinez-Olmos M A, Hillman N, Grande C, Pallardo F. Factors related to successful outcome after rapid weight loss in obese patients with NIDDM (Abstract). Int J Obesity 1995, 19, 2, S135.

Hanefeld M, Welk M. Very low calorie diet therapy in obese non-insulin dependent diabetes patients. Int J Obesity 1989, 13, 2, 33-37.

Berg F M. Effectiveness of treatment. Health risks of obesity. Obesity and Health 1993, 85-89.

PDF version: 1-OBESE-PATIENTS-IN-UK-GENERAL-PRACTICES-LOSE-16-TONNES

DIABETES AND OBESITY: HAVE YOU THOUGHT ABOUT LIPOTRIM?

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

 

GPs already know this and that diabetes, fuelled by an epidemic of overweight and obesity, is undermining the nation’s health. But it has been shown that with the aid of a very low calorie formula diet (VLCD), rapid weight loss leads to rapid remission of type 2 diabetes. A one-year study showed that BMI of obese diabetic patients was reduced by 5kg/m2 and that patients were able to discontinue insulin and oral hypoglycaemic agents for the whole year. 1 A five-year follow-up study confirmed that VLCD treatment was safe and effective in overweight diabetic subjects.2 It has also been shown that normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes is achieved by VLCD dietary energy restriction.3
Very low calorie diets and bariatric surgery are demonstrably the most effective weight loss methods for diabetic patients. Ultimately, it is the loss of the excess weight that leads to long

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

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

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

WEIGHT MANAGEMENT

Pharmacists are emerging as the weight management specialists, providing advice, treatments and support for the long-term maintenance of weight loss. Stephen Kreitzman and Valerie Beeson offer some background information to help tie together the complex issues surrounding weight management

The primary fuel for normal meTabolism is sugar. This simple and well-established fact provides the key to an understanding of the complex and at times confusing issues associated with managing body weight.

Sugar
‘sugar’ is a confusing term right from the start, since in common usage sugar generally refers to sucrose, the usual sweetener found on the table. in fact, however, there are many different sugars. The lactose in milk and the fructose sugars found in fruit and honey are very common in our diets. a healthy, normal diet should generally provide about 60 per cent of its calories from sugars in one form or another. The form in which sugars are presented to the body does make a difference. This difference, however, is usually more important in the digestive tract. before a sugar can enter the bloodstream, it must be digested (broken down from complex forms such as polysaccharides or even 2 unit sugars such as sucrose or lactose) into single unit sugars and then transported actively by carrier mechanisms across the gut membranes. What actually enters the blood, therefore, are primarily the simple sugars, glucose, fructose and galactose. if we are slow or unable to digest these complexes of sugars, they are considered fibre and provide different benefits to the body other than calories. for calories, the important sugar is glucose.

Glycogen
since glucose is critical for normal energy provision in our cells, there is necessarily some storage and there are three primary storage sites. Glucose is stored in the human body in the liver, in muscles and, very important for the understanding of weight management, in the fat cells. When glucose is stored at these sites, it is stored in the form of a complex polymer of
glucose called glycogen. Glycogen fact: There is a lot more of it in the fat of overweight people than in normal weight people. it is stored in a very hydrated form – 3–5 parts of water per part of glycogen. This means that a pound of glycogen stored in the body actually weighs between 4–6lb on the scales. Conversely, using a pound of glycogen for energy will show up as a 4–6lb weight loss. The water is simply excreted.

Weight loss
Tracking the weight of a dieter losing weight on a lowcarbohydrate, low but constant calorie intake shows very rapid weight loss initially, which very smoothly slows as less and less of the daily fuel used is glycogen. after the glycogen is essentially depleted, the subsequent weight change per day is virtually linear, reflecting the constant 3,500-calorie deficit per pound of fat weight lost and the constant intake. The consequences of the early loss of glycogen and associated water are familiar to most dieters. The initial days of weight change are heady since glycogen, a carbohydrate contributing four calories per gram to the daily deficit, will need a deficit of only 1,800 calories to use up a pound of glycogen and release another 4–5lb of water weight. This makes weight loss seem easy. it is an illusion. not only is glycogen repleted after the restriction is finished, but if the reintroduction of carbohydrates to the diet is not done properly, the repletion can actually deposit excessive glycogen and water. This would be a weight gain.

Body weight or energy stores?
it is necessary to distinguish changes in body weight from changes in the energy content of the body. failure to do so has led to laxative abuse and diuretic abuse. but as we have just discussed, loss of substantial amounts of water weight can be achieved by carbohydrate restriction. it can even be achieved by intensive exercise with several pounds of sweat lost. making changes in the glycogen and water stores of the body can be dramatic, but should not be confused with a loss of weight that reduces the energy reserves stored in the body. While it is essential, regardless of the methods employed, to produce a calorie deficit and subsequent weight reduction, to first deplete the glycogen reserves, it should be clear that drastically reducing the intake of carbs will produce an initial weight loss regardless of the calorie content of the food consumed. it should be just as clear, however, that if the calorie content of the food is in excess of that used, the overall energy stored in the body will be increased even while there may be a measurable and possibly substantial weight reduction on the scales. This
is the same as a secured bank loan. it will be paid back. The lost water weight will be easily regained. in order to reduce the energy stores of the body it is absolutely necessary to consume less calories than are used.

Nutrients in a low-calorie regime
There is no secret or magic to weight management. The calories eaten have to be considerably less than those being used for a sustained period of time. but professionals understand that continued health of the patient requires the patient to consume all the essential nutrients necessary for life and health. This becomes increasingly difficult as the amount of food consumed is reduced. We eat collections of plant and animal material every day and if we maintain a varied selection of foods, we can feel reasonably confident that we are getting the complete array of essential nutrients. The plants and animals we choose for food, however, each have some of the essential nutrients required by man, but none have them all. To get the right amounts for sustained health it is absolutely essential that we eat in excess of 1,200 calories. not because there is some metabolic danger related to the low calories, but simply because eating foods with lower calorie totals cannot provide all the nutrients needed by people.

The myth
experience showed that dieters eating less than about 1,200 calories a day frequently became ill. so a myth arose that dropping calories below about 1,200 in order to lose weight was unhealthy. it was, but not because the calories were low. a fat person has an enormous store of calories available. no additional calories are really needed while dieting. Supplementing with the missing nutrients, however, permits dropping the calorie intake much further without harm, as long as there are reserves of fuel left in the body. Fuel for the body is limited to glucose (and stores as glycogen) and fat. an obese individual has about 37,000 calories in reserve for each stone of excess weight and therefore has no realistic need to eat more. They just need to get the essential nutrients. When these come from a nutrient-complete formula food, the results are ideal: complete nourishment in minimal calories, only those contributed by the essential nutrients.

Fat versus carbohydrate for energy storage
it is fortunate that we store most of our excess calories as fat rather than as carbohydrate. 7,000 excess calories stored as fat adds an extra 1kg to our body weight. storing the same excess calories as glycogen and water would add close to 10kg. it does mean, however, that lowering the body content of energy stored as fat is necessary and requires a larger calorie gap to achieve than is necessary for glycogen.

Weight loss services in pharmacy
Dealing with weight management as a professional service in the pharmacy is considerably more effective when dieters are made aware of the differences between weight loss and loss of fat. Dieters need to understand the components of their lost weight – glycogen and water usage before fat. They need to understand how to restore the correct physiological balances after a period of calorie restriction to minimise recidivism. They need to understand that excessive protein intake during dieting may inhibit the resorption and utilisation of excess skin.
They should understand that the health outcome after a period of calorie restriction depends on the quality of nourishment available during calorie restriction. simply considering calories and not the nutrient needs of the body will undermine overall health. and the pharmacist needs to understand that in the very fat person, the first 10 per cent or so of body weight lost is primarily glycogen, with minimal fat. The 10 per cent target is usually the beginning of the depletion of the excess energy stored in the body fat, not the endpoint.
Pharmacists are emerging as the weight management specialists, providing lifestyle advice, effective treatments and support, and follow-on help for the most difficult aspect of managing weight: the long-term maintenance of weight loss.

PFD version: 1-4-weight-management