Proposals to tackle obesity are getting tougher, but pharmacies can demonstrate the contribution they can make to weight loss and digestive conditions, reports Charles Gladwin

Until now, the NHS had not considered weight loss surgery for people with a body mass index (BMI) below 40 kg/m². The limit was lowered to 35kg/m for people with other significant disease that could be improved if they lost weight.

But in July, NICE proposed extending the criteria to people with recent onset type 2 diabetes. Those with a BMI of 35kg/m2 or over will automatically be offered assessment for bariatric surgery, and those with a BMI of 30kg/m2 or more will be considered. People of Asian family origin could be assessed for bariatric surgery at lower BMIs.

Potentially, up to 850,000 additional people could become candidates for surgery, although it is expected that only 5,000 - 20,000 operations would take place each year. One immediate reaction was that the £5,000 or so cost of surgery per person could be better spent getting people onto weight reduction programmes earlier on.

But what programme to recommend? The draft NICE guidelines recommend against routinely using very low calorie diets (800kcal/day or less) to manage obesity. It reserves VLCD for use as part of a multi- component weight management strategy for a maximum of 12 weeks in obese people who have a clinically-assessed need to rapidly lose weight.

This may come as a blow to pharmacists who offer the VLCD-based Lipotrim weight management programme and have seen customers succeed in losing weight. The Lipotrim programme also includes the benefits of seeing a health professional on a weekly basis, allowing interventions such as medication review if needed.

Success with Lipotrim

Using Lipotrim, pharmacist Brendan Feeney has helped nearly 2,000 patients lose at least 5 per cent of their initial weight. Of those, 990 lost over 10 per cent of their initial weight. In addition, 218 lost more than 30 per cent of their initial weight. The average initial BMI was 42.4, but after dieting it dropped to 27.1.

The Lipotrim pharmacy programme comprises “total food replacement products with a structured pharmacist-led screening, monitoring and support programme.” So this philosophy is in line with NICE’s recommendation that if a VLCD is used, benefits and risks should be discussed. Patients should also be advised that VLCDs are not a long-term weight management plan, and that regaining weight is not down to a dieter’s own, or their clinician’s, failure. Longer-term advice should talk about reintroducing food and maintaining a steady weight.

Fin McCaul, of Prestwich Pharmacy in Manchester and Independent Pharmacy Federation chairman, says: ‘‘We believe that much greater use of the community pharmacy network to deliver weight loss programmes is essential. (Lipotrim) is a cost- effective and, most importantly, a successful way to achieve a reduction in weight which will assist with reducing the risks of other health complications, social impacts and employment opportunities.”

The pharmacy value

With weight management programmes well- established in pharmacies, research is demonstrating pharmacies’ value as weight management centres. Research conducted jointly in Australia and the UK asked 610 women about using pharmacy-based weight management schemes1.

Women who had visited a pharmacist to seek health advice in the previous 12 months were significantly more likely to want a pharmacist involved in their ideal weight management programme or for their ideal weight management programme to be located in a pharmacy, said the researchers. “Women pharmacy consumers in both Victoria (Australia) and Nottingham are comfortable with pharmacists being involved in the provision of weight management recommendations and have also illustrated the areas in which women pharmacy consumers need additional advice. Future educational resources for both populations should focus on evidence-based weight management approaches, weight loss goals, weight loss duration and benefits of weight loss.”

The Coventry scheme

Alliance Healthcare has flagged up the findings of a weight management programme that ran in four PCT areas, having been piloted in Coventry2. The scheme helped 15 per cent of participants achieve at least a five per cent weight reduction by their last appointment. Statistically significant reductions in blood pressure were seen at six months in two-thirds of participants.

Report author Dr Helen Boardman, of the University of Nottingham, comments: “A weight management programme needs to be one that (people) can complete alongside their work and family commitments. Pharmacies, with their longer working hours, may be an ideal place for some patients to obtain the support they need to assist them in losing weight.”

Sanjay Pathak, head of Alliance Healthcare's Pharmacy Professional Services, added: “We believe this evidence strengthens the case for future commissioning opportunities and will ensure that community pharmacy remains part of the core proposition when planning any future services.”

Gluten-free diets

Weight management is not the only aspect of diet that pharmacy helps with. Food allergies and intolerances such as coeliac disease are something that pharmacy has been involved with for years.

Much greater use of the community pharmacy network to deliver weight loss programmes is essential

In April, a year-long trial of the Gluten-Free Food (GFF) Additional Pharmaceutical Service started in Scotland’s pharmacies. Instead of asking the GP for prescriptions for gluten-free foods, patients register with a pharmacy. The pharmacy dispenses GFFs directly without a prescription, with quantities determined by assessed clinical need and recorded on the patient’s pharmaceutical care record so that reimbursement can be claimed each month. Pharmacists are paid £125 a month for taking part.

The scheme was piloted in Tayside Health Board over the past two and a half years, before being rolled out nationally. Glutafin has been involved in training, and has launched a range of resources for health professionals including CPD modules, educational events and pharmacy ‘support boxes’. These include a guide to coeliac disease, product information, samples and a window sticker to help promote the GFF Service.

Glutafin comments: “With the NHS promising to ‘unlock’ pharmacy’s potential in treating complex need, this gluten-free trial is a pivotal example of pharmacists taking a greater role in the medical community. The benefits could also extend to the NHS. Initiatives rolled out in Northamptonshire and Cumbria showed cost savings of 20-40 per cent when gluten-free foods were supplied direct from community pharmacies, which, if applied nationally, could save the government between five and 11 million pounds per year in England alone.”

The charity Coeliac UK has also issued a toolkit for commissioners. The pharmacy-led prescribing toolkit deals with community pharmacy-based GFF supply schemes and was drawn up in partnership with PSNC and the NPA. Highlighting the benefits of such schemes, it says: “The establishment of a local enhanced service allows commissioners to standardise the amounts of gluten-free food supplied to different groups of patients, which addresses concerns within the NHS in regards to excessive prescribing and off-tariff prescribing.”

In July, health minister Norman Lamb pointed out that “NHS England can commission a gluten-free food supply service as a local enhanced pharmaceutical service in the light of local need.” However, he added that neither the government nor NHS England “have plans to issue guidance on these schemes.”

References

1. Fakih S et al. Comparing women pharmacy consumers’ experiences with weight loss treatment in Victoria and Nottingham: a cross-sectional study. BMC Public Health 2014;14:662.
2. Boardman H et al. Effectiveness of a community pharmacy weight management programme. International Journal of Clinical Pharmacy. June 2014.