After reading this feature you should be able to:
• Use resources to plan, develop and improve weight loss services
• Recognise the signs of malnutrition
• Provide balanced advice on weight management and nutrition
Nutrition and weight are two topics much loved by the media. Barely a day goes by without one or the other – or both – warranting a news item. However the headlines can often seem contradictory, with one publication warning of an obesity epidemic while another runs a story on nutritional deficiencies.
Although it is a tall order, community pharmacists and their staff have to find a way to balance the two sides of this debate so that they are able to provide the right advice as befits their standing as health professionals on the high street.
Part of the problem lies in the fact that the issues of weight and nutrition are intertwined. Unlike other health conditions – cholesterol levels, for example, may be high or normal but never both at the same time – obesity and poor nutrition aren’t necessarily mutually exclusive.
Someone with a body mass index that is considered unhealthy won’t necessarily be eating too much across the board, but may well be ingesting too many calories from one food group at the expense of another. This is something that Eoghan O’Brien, pharmacist proprietor of Bannside Pharmacy in Portglenone, Northern Ireland, has come across.
Since 2012, Numark member Mr O’Brien has been involved in a “Biggest Loser” initiative set up by a local sports club as a fundraiser. The first year saw him give a talk to the 90 participants on the health benefits of weight loss, but since then, he and his staff have become increasingly engaged with the scheme by providing an alternative location for the weekly weigh-ins and conducting blood pressure checks during and after the nine-week programme.
Mr O’Brien’s interest in this area has grown to such a level that last year he secured a bursary from the NPA’s health education foundation and additional funding from his local health and social care trust to run a 12-week weight loss programme solely through his pharmacy. As well as weekly weigh-ins, patients had their blood glucose, total cholesterol and blood pressure measured at weeks one, seven and 12.
The results of this pilot project are currently undergoing evaluation at the University of Ulster, and Mr O’Brien is hopeful that he will be able to use the findings to develop a service model that is both flexible and scaleable enough to be run by pharmacies across Northern Ireland.
Interestingly, the Bannside Pharmacy weight loss service – and the “Biggest Loser” initiative run by the local sports club that inspired the pharmacy scheme – relies on lifestyle, rather than pharmacological, interventions.
As well as benefiting from health screening, regular weigh-ins and body measurements, participants receive advice on diet, nutrition and exercise, and can try out activities such as yoga, circuits and spin classes at local venues free of charge thanks to a voucher system that has been put in place.
A holistic approach is key, says Mr O’Brien: “We also do a wellbeing assessment on mood, using a simple NHS Choices questionnaire, because if someone can get their mental health right, good physical health generally follows.
Someone who is feeling down or depressed is likely to find it difficult to be motivated to make better food choices and become more active, so it is vital to consider someone’s mood and levels of self-confidence and self-esteem as part of the programme.”
This approach is very much in line with the model of care described in the recently published NHS Five Year Forward View. This vision document laid out the need for flexible models of service delivery tailored to local population and needs, with barriers broken down between physical and mental health, which is precisely what Bannside Pharmacy is already – and instinctively – doing.
The Five Year Forward View makes it clear that weight management is one of the issues that the NHS needs to get to grips with, as part of the shift towards prevention and public health that is crucial for the future health of the country’s children, the sustainability of the NHS and economic prosperity.
While the NHS document says that there will be national action to try and tackle the obesity epidemic – a push towards clearer food information and labelling and the roll-out of preventative service programmes in an attempt to stem and ultimately reverse the upwards trend in spending on bariatric surgery, for example – it is also clear that much needs to happen at a local and individual level.
Public spending cuts mean that a national pharmacy weight management service is unlikely to be commissioned any time soon, but that doesn’t mean the sector should hold back from trying to meet what is a very real and present health priority. Much like Bannside Pharmacy, some pharmacies are encouraging overweight customers to make lifestyle changes, whereas others have opted for a programme that uses pharmacological aids such as Lipotrim.
More still employ considerably lower key and informal tactics, whereby various weight loss aids are kept in stock, and advice and recommendations made on an opportunistic basis.
All of these methods have one thing in common: a need to stay abreast of current developments and thinking on obesity and weight management, so that the advice and support provided to patients is as up-to-date as possible. A good starting point is Public Health England’s obesity website (noo.org.uk), which incorporates the work of the former National Obesity Observatory.
The site pulls together a wealth of information on obesity, including data, research papers, guidance and news items. Of particular value to any pharmacy wondering whether there is demand for weight management services in their area is the “data and tools” section, which has links to information on both adult and child obesity at a local authority level.
Other useful resources include:
• The NICE pathway on obesity (pathways.nice.org.uk/pathways/obesity), which links to guidance on weight management in both adults and children
• The Centre for Pharmacy Postgraduate Education’s distance learning package entitled “Weight management – understanding the causes, prevention, assessment and management of obesity” (cppe.ac.uk/programmes/l/weightman-p-01/)
• Draft template service specifications for weight management in adults and children and examples of services that have been commissioned locally can be found on the PSNC website (psnc.org.uk/services-commissioning/locally-commissionedservices/weight-management-services/).
An added complexity of the UK’s relationship with body weight is that while obesity levels are rising, so is food poverty. For increasing numbers of people in the UK, money is tight, which is forcing some into choosing cheaper, processed foods just to get by. These foodstuffs are often high in sugar and fats, which provide the energy people need in the short-term, but are lacking in the vitamins and minerals that are essential for good health. This can result in individuals being overweight or obese, yet at the same time suffering from malnutrition.
According to data from the health and social care information centre, in the year to April 2014, 6,690 people were admitted to hospital with a primary or secondary diagnosis of malnutrition – over 1,000 more than the previous year. Over five years, there was a 71 per cent increase. The UK faculty of public health (UKFPH) points to food poverty as a reason for this, with vice president for policy John Middleton stating: “Food prices have gone up by 12 per cent since 2007while wages fell by 7.6 per cent in relative terms. At the same time, fuel bills, which make up a bigger part of the incomes of people living on low incomes, have increased.”
For increasing numbers of people in the UK, money is getting tighter, which is forcing some into choosing cheaper, processed foods just to get by
Dr Carrie Ruxton, dietitian, the Meat Advisory Panel, looks at the health benefits of adopting a ‘Palaeolithic’ diet
Just as modern man has come a long way since our time as hunter gatherers, the modern Western diet has changed beyond recognition. While this is good for food safety and enjoyment, there are several nutritional drawbacks. Official dietary advice continues to promote high intakes of starchy carbohydrates, fibre, fruits and vegetables, alongside reductions in fat, salt and sugar. Yet some experts argue that the low carbohydrate, high protein, meat-rich diet of our ancestors is more natural.
Modern man is genetically stone age and, thus, adapted to consume the types of foods found in the late Palaeolithic period such as game meat, fish, shellfish, fresh fruits and vegetables, roots, tubers, eggs, and nuts. Studies suggest that the ancient diet was higher in protein and lower in carbohydrates compared with modern diets. Intakes of unsaturated fatty acids were elevated, while intakes of saturated fats were low, with trans fats, dairy products and refined sugars absent. Fibre intakes were around 100g per day, which is five times what we eat today.
It is a misconception that Palaeolithic diets were mostly vegetarian, based on research on modern hunter gatherers who consume two-thirds of daily calories from animal foods. Other evidence comes from isotopic analyses of hominid collagen tissue, human gut morphology and encephalisation, as well as foraging data. One paradox of Palaeolithic diets is the apparent lack of association between high meat diets and cardiovascular disease.
Red meat is often highlighted as a risk factor in US observational studies but modern hunter-gatherers, despite consuming far more meat than is recommended nowadays, have a lower incidence of chronic conditions. This may be because lean red meat contributes significant amounts of nutrients believed to support heart and immune health, including omega-3 fatty acids, iron, zinc, selenium, thiamin, vitamin B12 and vitamin D. Genuine Palaeolithic foods are in the past but we can still learn from our ancestors’ diets by choosing lean red meat (500g per week), fish, fruits, root vegetables, eggs and nuts, and cutting back on processed foods, alcohol and sugary drinks. See meatandhealth.com. (References available upon request)
UKFPH’s claims are supported by statistics provided by The Trussell Trust, which says that just under 350,000 people were provided with three days’ emergency food from its food banks in 2012-13. The figure for 2013-14 is substantially higher at just under 915,000, with the biggest uptake occurring in the north west of England. And this is just the tip of the iceberg, as The Trussell Trust is only one of several organisations involved in setting up and managing food banks across the UK.
There are obviously reasons other than food poverty for someone becoming malnourished, ranging from physical factors such as poor dental health, appetite loss as a result of anosmia (loss of sense of smell) or ageusia (lost of taste sensation), or disability causing difficulties in cooking or food shopping, to medical factors such as cancer, chronic pain, depression, dementia, dysphagia, persistent diarrhoea or vomiting, an eating disorder or a digestive condition, and social factors such as isolation, substance dependence and low income.
Malnutrition is not always easy to pick up. The most obvious symptom is unintentional weight loss (anything above five per cent of body weight over a period of less than six months should raise alarm bells, although sufferers may be more likely to notice clothes and jewellery becoming looser), but this doesn’t occur in cases where obesity or being overweight exist concurrently.
Other signs of malnutrition can include fatigue, lethargy, delayed wound healing and recovery from infections, poor concentration, depression, irritability, finding it hard to keep warm, and persistent diarrhoea.
In children, failure to grow in both weight and height as expected is an indicator, but the condition may also present with behavioural changes such as anxiety, lack of energy and moodiness, and subtle alterations in hair and skin colour.
People who are diagnosed as malnourished should be assessed to establish the root cause and, in many cases, the factor causing the problem can be identified and resolved. However, where malnutrition occurs as a result of food poverty, the solution is primarily in the sufferers’ hands but the pharmacy team can help support them in making better dietary choices.
Getting the balance right
Tips that can be passed on include:
• Careful menu planning to maximise ingredients and minimise waste. Buying a whole chicken, for example, is considerably cheaper than purchasing the constituent parts and can stretch to several meals
• Using and sticking to a shopping list based on the menu planning
• Cooking from scratch rather than buying ready meals or takeaways
• Making the most of the freezer by using it to store leftovers and ingredients that are cheaper than fresh (this is particularly relevant for vegetables)
• Using cheaper protein sources such as pulses
• Shopping from the reduced to clear shelves in supermarkets.
There are many resources available that can help people cook and eat well on a budget.
• The NHS Livewell Eat4Cheap site (nhs.uk/Livewell/eat4cheap)
• BBC Good Food’s Cheap and Healthy section (bbcgoodfood.com/recipes/collection/cheap-and-healthy)
• The British Nutrition Foundation (nutrition.org.uk/healthyliving/healthyeating/budget.html).
Food retailers, in particular the supermarkets, have also woken up to their responsibilities towards shoppers for whom purse strings are tight, and often have recipe cards in-store and information on their websites for this group.