Tag Archives: weight reduction

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 Research

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.

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 management

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.

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.

PDF Version: todayspharmacist

OBESITY PREVENTION AND TREATMENT ON THE HIGH STREET

S. N. Kreitzman Ph.D, R.Nutr.

Howard Foundation Research

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. Take weight management for example. 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. This point was very well illustrated in a recent article in GP magazine that reported a staggering sevenfold rise in insulin use in type 2 diabetes over a nine year period.

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.

Fin McCaul, for example, is first and foremost a community pharmacist practicing in Manchester. He is also the Chairman of the Independent Pharmacy Federation and works for Bury CCG one day per 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 1000 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 he organised a series of Patient Services Workshops delivered by Pharmacists who are successfully running weight services in their local community and want to share their knowledge and expertise.

Fin’s expertise and results are not just anecdotes. He, along with many of the pharmacies treating overweight and obesity are generating extensive audit data from their weight management services. Results from one of his pharmacy audits below show the percentage of initial weight lost by over 1100 of his patients.

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 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 the morbidly obese people. This is a group who could have qualified for bariatric surgery at great expense, risk and often compromised future life.

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 therefore continuing with hypoglycaemic medication can get them into serious difficulty. There are multitudes of patients taking medications such as warfarin or lithium, drugs which have a very narrow safety spectrum. Dieting can alter the absorption rate for these drugs so these patients need their dosages 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. Effective weight loss should not be left to amateurs or internet sales. Healthcare professionals are needed, especially in pharmacy where continuous care can be provided even after the weight is lost, because weight maintenance requires the greatest attention and is not usually possible in a busy medical practice and appears to be almost impossible without professional help.

Although it is traditional to show successful dieters proudly occupying trousers which are now several sizes too large, there isn’t enough space to print over 13,000 examples. Results from this single audit of a group of pharmacies out of a collection of more than 2000 UK and Irish pharmacies currently treating overweight and obesity, is a vivid demonstration of the evidence base being accumulated for this absolutely essential community service from pharmacy.

Pharmacy is the only reliable community service providing and documenting long term weight management without the need major research grants or health service funding. Although there has been widespread press coverage for a £2.4 million grant by Diabetes UK to attempt to demonstrate that type 2 diabetes can be put into remission by effective weight loss, a fact that has been repeatedly reported in the medical press for over 30 years, pharmacies have been quietly and routinely succeeding with diabetes prevention and remission in their high street branches. Unlike bariatric surgeons, who need to justify the cost and risk of providing weight loss by surgical means on the basis of the phenomenal cost savings on the treatment of diabetes alone, weight loss in the pharmacy can accomplish the same results without massive expense and risk. And since total food replacement methods remove the substances of abuse for prolonged periods of time from those who may be suffering from a dopamine response to eating excess in their nucleus accombans , they don’t show the common addiction transfer syndrome that seems to be so common after bariatric surgery.

While activists continue to bellow about the size of soft drink containers, pharmacists are demonstrating how much their education and skills can be amplified by the convenience of access on the high streets of the UK. Pharmacy stands alone among the healthcare professionals in providing fantastic public health services such as smoking cessation, weight management, diabetes recognition, prevention and even treatment, medicines review, hypertension assessment and a host of other essential services very much needed in the real world. A major thank you is overdue.

PFD version: OBESITY-PREVENTION-AND-TREATMENT-ON-THE-HIGH-STREET

Promoting adherence to your weight management service

Jun 2012

Adherence is an area that pharmacy is claiming for its own. The New Medicines Service (NMS) and Medicines Use Reviews (MURs) are both based on promoting adherence to prescribed medication.
But what about adherence to weight loss? The principles of adherence are the same and the semi structured questionnaire used in these services could be adapted for your weight management, for example by asking the customer how they are getting on, if they are having any problems, if they think it’s working, if there have been any lapses and if there is any further information or support they need.
However, weight loss, like smoking cessation, are complicated by an addiction element (one to food, the other to nicotine) so
any counselling will also take into account motivation and willpower.
The Lipotrim Pharmacy Programme has been designed to help patients adhere to the diet and maintain their weight afterwards. Total Food Replacement with Lipotrim uniquely allows the dieter to totally stop the substance of abuse, which is an essential component of addiction management. The initial consultation and subsequent weekly visits help you to educate and encourage dieters and address any concerns. This gives dieters confidence in your service and also means you can help them maintain their target weight, such as with Lipotrim maintenance products.
The programme also comes with resources and tools which include factsheets, patient progress cards and a new engaging patient DVD that uses the latest animation to explain weight loss and the Lipotrim programme. The Lipotrim Pharmacy Patient Tracker has a patient interface, complete with graphs and charts, which means patients can login securely into their records and monitor their own progress to keep motivated.

PDF Version: ICP LIPOTRIM COLUMN June r1 FINAL

Capitalise on HLP to drive your weight management service

May 2012

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
before roll-out.
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.

PDF Version: ICP LIPOTRIM COLUMN May r1

Worth the weight

The market for weight loss products is moving in the direction of a personalised, supportive and structured service offer, says Christine Michael

At New Year millions of people are likely to resolve to lose weight and get fitter, but all too often their good intentions prove short-lived, and obesity remains an intractable public health problem. Data compiled by the World Cancer Research Fund show that in 2010 in England, 62.8 per cent of adults were overweight or obese, and the direct cost of obesity related illness to the NHS was estimated at £5.1bn a year. In Scotland, 65 per cent of adults were overweight or obese, while the figures for Northern Ireland and Wales are 59 per cent and 57 per cent respectively.
For pharmacies, January and February are key times of the year to engage with customers who want to slim, whether on an opportunistic basis, as part of a broader healthy lifestyle offering, or as a commissioned enhanced service.
Keeping track
NPA Board Member and Alliance Healthcare Awards Welsh Pharmacy of the Year shortlisted nominee,

Chris Jenkins, of St Clears Pharmacy in Carmarthenshire, introduced a weight loss service earlier this year, and says it has created a “virtuous cycle” for the pharmacy as a whole. “We enjoy a positive reputation for our successful weight management service, strengthening our position and creating a benchmark in customer care within the local community,” he says. “More than 50 people have enrolled, and some travel up to 30 miles for the service; it even has a local Facebook page.”
One advantage of offering a service based weight loss programme rather than a more ad hoc approach is the opportunity it provides to compile data for potential commissioners. This lies behind the introduction of a ‘Patient Tracker’ audit tool, a new feature of the Lipotrim VLCD programme, which has been running for 25 years and is now available in nearly 2,000 pharmacies. “It is important to have the tools that can satisfy the need for documentation of achievement in this era of evidence-based treatments,” says Gareth Evans, a community pharmacist who offers the Lipotrim programme in East Anglia. His analysis shows that the mean weight loss of 382 people who completed three or more weeks on total food replacement was around 10kg, from 91kg to 81kg on average. “The Patient Tracker software allows me to present evidence not only of individual patients’ experience but also the achievements of cohorts of patients, which has become important for commissioning – for example, to show that successful weight loss is found even in patients with extremely high BMI,” says Mr Evans.

Diet demand
Market analysts Euromonitor International sees growth in `one stop shop’ weight loss services like the Lipotrim programme, as consumers “shift away from weight loss tablets and pills, and towards meal replacement programmes and holistic diet alternatives… due in part to the prevailing economic conditions”.
Its analysis shows some volatility in the retail weight loss category, explained mainly by the dramatic impact of Alli, from GlaxoSmithKline Healthcare (GSK), from its launch as an OTC product in 2009, to a subsequent fall off in sales in 2011.
However, having resolved difficulties with supplies of the product, GSK relaunched Alli in time for the 2012 Christmas and New Year market. Their major campaign of press and online advertising and in-store support, was primarily aimed at females aged 35 and over, with a BMI of 28 or more.
Nevertheless, Euromonitor still forecasts virtually flat sales in the category between 2012 and 2016, with compound annual growth of only 0.4 per cent, rising to an annual total of £128.6m by 2016.
One catalyst for change in the slimming supplement market is the latest batch of claims guidelines from the European 27Food Safety Agency (EFSA), which came into force in December 2012, and which may now lead to some products that make unapproved claims being withdrawn or relaunched with amended packaging.

Products with approved claims are likely to benefit, says Sanjay Mistry of Inovate Health. His company markets Slimsticks, a product containing konjac mannan, a vegetable fibre that the EFSA approves for “weight loss in the context of a hypocaloric diet”. Launching with a short term listing in selected Boots stores, Slimsticks will be rolled out to independent pharmacies through 2013. Other products that have EFSA approved claims are also now likely to want to push their advantage.
Compared with offering slimming products, introducing a personalised service may seem onerous in terms of time and training, but Chris Jenkins believes it is still worthwhile.
“Two members of staff have taken full responsibility for the weight loss service and have great pride in doing this,” he says. “They have the chance to develop new skills, and although it takes time to run such a service it is well invested time – time to care for patients and to make a real difference in their lives.”

PDF Version: Weight-loss-Jan13

LIPOTRIM PHARMACY WEIGHT LOSS PROGRAMME : EVIDENCE BASE

Providing routine clinical evidence documenting efficacy in pharmacy under real life conditions

There is probably no current medical discipline more in need of evidence of efficacy than the field of weight loss, especially when the patients are obese and/or with co-morbidities. There is now overwhelming experience with total food replacement programmes (VLCD) , nutrient complete formula diets that are essentially low fat, very low calorie enteral feeds. Over the past four decades, these have gained recognition and acceptance as safe and effective where they are supervised by healthcare professionals, people who are medically experienced so that they can restrict access to the diets or modify treatments when necessary. Real weight loss, beyond simply depleting stored glycogen and water, has physiological implications and the real weight losses due to VLCD programmes, such as Lipotrim, are rapid and substantial. These programmes, run by trained pharmacists and GPs, compete with bariatric surgery in the magnitude of the losses routinely achieved, but without the negatives of substantial costs, higher risks and post weight loss addiction transfer,

EVIDENCE BASE

While a total food replacement formula diet can obviously not be blind to the dieter and a placebo would be unsafe, an innovative patient tracker system introduced into the Lipotrim pharmacy weight loss programme, allows for on demand, virtually instant, assessment of the secure data kept by the pharmacists offering the service. Statistical evidence can be provided for an individual patient or all the patients from a particular medical practice. Evidence can be provided for a single pharmacy or a pharmacy group or, as required, any selected collection of pharmacies, If necessary evidence can be provided from all the pharmacies in an area, as was recently reported for 150 pharmacies in Northern and Southern Ireland by pharmacist Brendan Feeney.

The flexibility of the tracker is such that statistics can be obtained, for example, within a defined BMI range, such as above BMI 40 or perhaps between BMI 25 and 30, or a defined age range or by gender. It can compare the first dieting period with that of subsequent dieting intervals. It can provide statistics on long term weight maintenance after dieting and the stability of the weight during transition from dieting to maintenance.

Critically, it is possible to quantify the dieting successes of people with concurrent medical issues – diabetes, high blood pressure, hypothyroid, depressive illness or any medical condition where weight loss will have an impact on the condition or treatment protocols. The Ireland assessment, previously referred to, provided statistics of the magnitude of the weight losses, the percent of initial weight lost and BMI changes for a cohort of type 2 diabetes patients – all of whom stopped oral diabetes medications prior to dieting, and remained in remission long after the documented weight loss.

Pharmacist Fin McCaul of Prestwich pharmacy and chairman of the Independent Pharmacy Federation, recently presented data to a National Obesity Forum Conference based on a successful cohort with an initial BMI in excess of 40. At Prestwich 1148 patients with a median BMI of 33.6 kg/m²used the Lipotrim weight management service. 25% were morbidly obese with a BMI > 40 kg/m². At the time of audit, during which many patients were still dieting, the median BMI had decreased to < 30 kg/m². 94% of the dieters lost more than 5% of their pre-diet weight, 47% lost more than 10% and 21% of the patients lost more than 20%. Importantly, all patients with type 2 diabetes had their medication stopped by their GP.

Providing clinical evidence of efficacy under real life conditions, is now routine for pharmacists offering the Lipotrim weight loss service and documenting results with the Patient Tracker software.

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CONTRASTING THE BENEFITS OF VERY LOW CALORIE DIETS AND BARIATRIC SURGERY

By S.N Kreitzman,V. Beeson and S.A. Kreitzmanof Howard Foundation Research Ltd

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.

PDF version: contrast vlcd & surgery pharmicist 2012(1)

SHARING WEIGHT MANAGEMENT ADVICE WITH PATIENTS

We all know that the key to weight loss is eating less and exercising more. However, dropping to under 1,200 calories without supplementation leads to nutrient deficiencies, which perpetuates the myth that lower calorie diets are dangerous

It is comforting to know that nurses are one of the few groups left who understand the suffering experienced by patients who are overweight and who recognise obesity as a problem worthy of effective action. Weight control is difficult and unfortunately it is much easier to eat calories than it is to exercise them away. A calorie gap of 3,500 calories between the calories eaten and those used is necessary to dispose of a single pound of excess body fat – 3,500 calories represent
a substantial amount of exercise. If the calories actually eaten are more than the calories used by the other activities of the day, the exercise will only reduce the calorie excess and not result in weight loss. It might, however, slow the weight gain. It really is necessary to eat less in order to manage weight.

No easy solution

There is no secret to weight management: the calories eaten have to be considerably less than those being used for a sustained period of time. The continued health of the patient requires them to consume all the essential nutrients necessary for life and health, which becomes increasingly difficult as the amount of food consumed is reduced or treatments actively promote malabsorption.
If we maintain a varied selection of foods, we can feel reasonably confident that we are getting the complete array of essential nutrients. However, while the plants and animals we choose for food each have some of the essential nutrients required by man, none has them all. To get the right amounts for sustained health from unsupplemented foods it is absolutely essential that we eat in excess of 1,200 calories. Eating foods with lower calorie totals cannot provide all the nutrients that we need. The myth that dropping calories below about 1,200 in order to lose weight is unhealthy is true, but not because the calories are low – a fat person has an enormous store of calories available. The problem is that dieters become nutrient deficient.
Providing 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. Fuels available for the body are glucose (stored 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. He just needs to get the essential nutrients. When these come from a nutrient-complete formula food, the results are ideal: complete nourishment and minimal calories. Supplying the essential nutrients in a prepared mixture, such as in an enteral feed, assures that nutrient deficiencies do not occur.

The role of the pharmacist

An expanding network of pharmacists is 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 very low calorie diets (VLCDs).1 These pharmacists are trained and experienced specialists in the use of VLCD.
Pharmacies following this route are achieving a great deal and GPs and nurses are becoming much more comfortable directing overweight patients to these highly trained and experienced pharmacists. At the same time the availability of trained pharmacists is becoming more widespread, which is making these experts much more accessible to a wider deserving population.

Conclusion

Weight loss is more than a cosmetic issue. 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, relieve sleep apnoea, provide an opportunity for patients to be considered for elective surgery, decrease the need for antidepressants, make exercise more possible and thus improve cardiovascular health, and vastly improve the quality of life for patients in a prejudiced and intolerant world. Pharmacists are emerging as the weight management specialists, providing lifestyle advice, effective treatments and support, as well as follow-on help for the most difficult aspect of managing weight: the longterm maintenance of weight lost. Your overweight patients will appreciate knowing about it.

PDF version: 4-3-sharing-advice

ADVANCED OBESITY MANAGEMENT TRAINING SOLUTIONS

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

THE EFFECTIVENESS OF VERY LOW CALORIE DIETS IN MANAGING OBESITY
Obesity is a serious problem in modern society, and one that needs to be urgently addressed by healthcare professionals. Unfortunately, widespread obesity management will not be possible until healthcare professionals accept the brutal fact that advising an obese patient to ‘eat less” is as misguided as managing an alcoholic by advising him or her to “drink less.”
In the first instance, advanced obesity management must recognise that there is a difference between people who become .)ese and the rest of the normal weight j,opulation. Not every drinker becomes an alcoholic, and in the same way, only some people become obese. This is not a trivial comparison. Many people can and do control their eating behaviour arid never appear to be in danger of escalation into obesity. For those who do become obese, however, their food behaviour often displays the compulsions and cravings of an addiction. Indeed, it is when food consumption is put into the context of other addictive behaviours that the nature of the roblem
becomes clear.
The link between addiction and obesity is finally now being reflected in the search for drugs to combat obesity, as can be seen
in the 30 July, 2010 report in the Lancet on the use of naltrexone in conjunction with bupropion as a weight loss treatment. It is important to recognise the basic fact that there is a component of addiction in food abuse and ultimately obesity. The most powerful long term treatment for addictions is complete abstinence from the addictive substance. A reformed smoker is someone who does not smoke, and a reformed alcoholic is someone who does not drink Comprehending this simple reality explains why total food replacement formula (very low calorie diets) are extremely effective and conventional low calorie diets are much less effective for seriously overweight patients. To treat any addiction (including obesity) effectively it is necessary to stop the substance of abuse. Very low calorie diets – essentially low fat enteral feeds – are absolutely necessary because they permit a patient to safely stop eating for prolonged periods. No lifestyle or behavioural change can be effective while the patient is caught in the biological quagmire of addiction. The advantage of a Total Food Replacement programme is that nutrition is provided by an engineered
formula that is nutritionally complete,
allowing the dieter to remove the addictive substance (food) from his or her life and remain healthy while the weight is lost. The value of a total food replacement formula programme in the treatment of overweight and obesity should now be obvious. TOTAL food replacementis the only means by which those who are subject to food abuse may avoid the addictive stimulus that perpetuates their weight problem.
EVIDENCED BASED CARE
The rapid proliferation of type 2 diabetes is currently one of the more serious healthcare problems. Current estimated costs to the NHS for treatment of this problem are a staggering El million per hour. In almost all cases however, a simple treatment exists that costs the NHS nothing, can 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 inadequately recognised because of the mantra for evidence based care. It is impossible to design a double blind placebo controlled study of VLCD.
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 VLCDs and monitoring their progress weekly over the course of their treatment. Those medical details and weekly progress reports have all been recorded over the years, and a number of audits from individual GP
practices and a 25 practice meta-audit have been published.
As the population of GP practices and pharmacies has expanded and computerised patient records have become more available, it has become Training to use VLCD properly requires education
Dieters can safely remove the addictive substance (food) and remain healthy theoretically possible to audit the entire population. A sample from a group of pharmacies in the Republic of Ireland has provided audit data for over 9000 Lipotrim patients. A single pharmacy in Prestwich, Manchester has provided audit data for over 1100 dieting Lipotrim patients. Since these patients are seen weekly and progress recorded by health professionals, the information should be viewed as highly credible and EVIDENCE BASED.
At Prestwich 1148 overweight patients with a median BMI of 33.6 kg/m’ were enrolled into the Lipotrim weight management programme. Of these, 25% were morbidly obese with a BMI >40 kg/ m2. At the time of audit, during which manypatients were still actively dieting, the median BMI had decreased to <30 kg/m2. 94% of the dieters lost more than 5% of their pre-diet weight, 47% lost more than 10% and 21% of the patients lost more than 20%. Importantly, all patients with type 2 diabetes had their medication stopped by their GP.’ The weight losses (comparable in most cases to that achieved by bariatric surgery) are having the same effect on type 2 diabetes as that reported for surgical procedures. The effect is in fact so dramatic, patients are not permitted to start the diet unless the GP has stopped diabetic medication. Blood sugars will normalize within a few days, and with afew weeks weight loss it is unlikely that any further diabetic medication will be required.
Training to use VLCD properly requires education. There are simply too many myths. The training programme for pharmacists running the Lipotrim weight management programme was awarded the SMART Best Educational Training Award For Pharmacists in 2002. Based upon sound physiological principles that most professionals know but are continuously seduced to ignore, there must be a greater recognition of need for VLCD, the only widely available tool for obese patients mired in the addiction aspect of food abuse. •
1. (Data presented at the 2010 National Obesity Forum Conference by Pharmacist Fin McCaul)

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USE OF VERY LOW ENERGY, NUTRIENT COMPLETE FORMULA FOODS, AS TOTAL FOOD REPLACEMENT FOR WEIGHT CONTROL

To fully understand the medical value of nutrient- complete formulated foods as a tool for weight management, there are a few fundamental concepts that need to be explained. These include the protein sparing modified fast; the mechanisms and value of ketogenic diets, minimum safe energy intakes and enteral food formulas. The value of this approach is amply demonstrated by substantial clinical evidence accumulated over a period of nearly 40 years.
Beginning in 1975, a series of reports from the Bistrian and Blackburn medical team demonstrated the value of a very low-energy dietary regime for weight management in a variety of difficult obese patients. This team had the advantage of considerable nutrition expertise and they devised a protein sparing modified fast — essentially a home-concocted Very Low Calorie Dietary formulation that was nutrient complete. Unfortunately the remarkable success (and safety) of this approach was obscured by commercial greed – not by the medical team, but by external commercial exploitation. A commercial product was developed and widely sold that contained virtually no nutrition. it was based upon a hydrolyzed nutritionally incomplete protein (collagen) in cherry syrup. This product was heavily promoted and widely hyped and inevitably, it resulted in a number of deaths.
Quite properly, the Liquid Protein Diets have not been available since the late 1970s. Unfortunately however, a total lack of nutritional understanding led to the assumption that low energy liquid formulations were dangerous as a concept. In fact there are now nearly 40 years of worldwide experience with numerous properly formulated nutritionally complete products which should be evidence enough of safety.
There is an often stated mantra, surprisingly even from nutrition specialists, that there must be some level of calorie intake (in the neighbourhood or 1000 to 1200 calories per day) below which diets become unsafe. Once again, it is simply the superficial understanding of food and nutrition biochemistry that has given this notion some credence. All common foods may be thought of basically as recycled nutrients from the plants and animals we choose to consume. All are complex formulations of the chemicals that make up the composition of those plants and animals. Many of these chemicals are common to all living things and some of them are useful and even necessary for human health. They also contain large numbers of chemicals that are either inert or toxic to other animals, including humans. The key point, however, is that there is no naturally occurring food that contributes all the required nutrients for humans. We therefore require a varied diet to attempt to create a mix that will maximize the chemistry we need and minimise the problematic substances.
The crucial point here is that – given the varying chemistry of the plants and animals we consume — it is virtually impossible to assemble a nutrient-complete daily diet with a total of less than around 1200 calories. When food diets with lower calorie intakes are provided, nutrient deficiencies invariably cause illness. It is very important to note here that it is the nutrient deficiencies — and not the low calorie count — that causes the problems.
When it became clear that nutrient complete enteral feeds could be provided that contained, by design, all the essential nutrients, it demonstrated that the minimum calorie intake was nowhere near the 1200 calorie barrier. In fact, modern formulations have a calorie component determined primarily by the calorie contribution of the essential amino acids and essential fatty acids (and to a lesser extent by the lactose from the necessary milk component, which provides very high quality proteins to the formulations). These limits however are closer to 400 calories per day, not 1200.
The most effective and safe formulations are those that induce ketosis. Ketones are a by-product of the incomplete breakdown of free fatty acids. They are essential for sparing protein utilization and helpful in controlling the hormonal balance between insulin and giucagon, which helps control hunger. Many of the body’s tissues can use free fatty acids as fuel, but critically there are a few (including the brain) that cannot. Unless there are sufficient ketones present, which are water soluble and can pass through the blood brain barrier to provide energy for brain function and survival, the body must de-aminate amino acids from proteins to create glucose. Glucose can not be created from fat. This is why ketones are protein sparing. Virtually all tissues, with the possible exception of liver, can use ketones for energy.
It is clear from the controlled accessibility of very low energy diets through healthcare professionals, that detailed records are available of the successful results of this form of treatment. A large number of these results have been published. Proper nutrition, provided in defined very low calorie formulations, results in maximum safe rates of weight loss and there is considerable evidence to support its value to modern medicine.
S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist)
V. Beeson Howard Foundation Research Ltd.

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Lipotrim Resources

VLCD diet resources from Lipotrim