Sultan Dajani gives the lowdown on what has made his pharmacy’s service such a success
The relationship between patients and pharmacists is different to that between patients and other medical professionals.
This is not just because of our ease of access, quality of service and convenience. Perhaps more importantly, we can make a real difference around public health services such as weight management because we have a strong foundation in medicinal as well as non-pharmacological expertise.
Our access and expertise plays a huge and unparalleled advantage in identifying groups of people either at risk of becoming obese or at special risk from being obese.
This includes people on low incomes who may have poor diets high in fat and energy, elderly people with arthritis who can maintain mobility more easily if they maintain a healthy weight, and Asian people, who are statistically at particular risk of diabetes and cardiovascular disease.
This is why the service we provide needs to be patient-centred and have the ability to integrate weight management to the patient’s health and quality of life.
We must not only provide psychological support and recommend making behavioural interventions, but we must also make interventions to increase physical activity and improve diet. Where appropriate, pharmacological interventions may also be provided.
Slow and steady
For my pharmacy, tackling patients’ obesity is not about fast weight loss, but sustained weight management. I looked at providing many services, from Lipotrim to providing exercise prescriptions and even arranged a voucher scheme with some of the local green grocers that allowed some of my customers on low incomes to get 10% off their fruit and vegetables.
We finally settled on a weight loss programme that allows access to orlistat (Xenical) via a private patient group direction (PGD), although I have since qualified as a prescriber. It works better than anything else I have ever seen.
A balanced healthy diet and regular physical activity should ideally be started before beginning treatment with orlistat and continue to be followed when treatment is stopped.
My weight loss programme is open to adults who don’t have eating disorders but do have a body mass index of 30 or more, or 28 or more plus other risk factors such as type 2 diabetes or high blood pressure. Before enrolling patients, I use a motivational questionnaire to assess whether the patient is ready to lose weight. It also acts as a back-up to say the right things and remind them of their goals when they experience a relapse or seem less motivated.
I’ve had patients on antipsychotics, steroids and thyroid medication who have to work harder for a smaller benefit and in these patients, success lies in motivating them to realise that even a weight loss of one pound a month will benefit their health.
Many patients have been living with weight management issues and obesity for 30 or 40 years, so there are major changes for them. Because of this, I try to add in a small, manageable change each month.
For example, in the first session I encourage them to eat less fat; in the second session I discuss reducing their portion size and in the third session I introduce the idea of exercise.
Some of my patients are well into their 60s and may have arthritic disease, so an activity such as cycling would clearly be unrealistic. For these patients, I encourage chair and flexibility exercises.
Each time, I use their own motivational reasons because I’ve learned how valuable motivation is to achieve better outcomes from the smoking cessation services I provide.
The first consultation takes 25 minutes and incorporates the motivational factors. I measure the patient’s BMI, blood pressure and blood glucose and provide practical guidance, advice on healthy eating, and individualised support for managing their lifestyle and increasing daily activity.
My message is not just about weight loss, but risk reduction of diseases such as diabetes and cardiovascular disease and other health benefits.
GPs are informed that their patients are taking part in the programme and patients will be referred to them if necessary. Otherwise patients will pay about £5 per week to join the programme plus the cost
of any pharmaceutical interventions.
The first interview is by far the most important because valuable background information is gathered, realistic goals are set, expectations discussed, a plan is agreed and any questions are asked and answered. There is no such thing as stating the obvious when it comes to weight management!
While diet in conjunction with exercise is the best approach, diet remains the cornerstone of obesity management. I’ve encouraged a few people to keep food diaries and then got them to assess for themselves how they could improve their diet. The emphasis should be on gradual weight loss as part of an overall weight management strategy.
Although achievement of a BMI within the 20-25 range is beneficial for an obese individual, even a 10% weight loss is beneficial in terms of disease risk reduction.
I avoid setting targets because the problem with setting people weight targets within the ‘ideal’ range is that they can so easily be set up to fail and this can reduce self esteem. For some patients, diet and exercise do not make enough impact on their condition and that’s when I advise a pharmaceutical intervention.
What does success look like?
My weight management scheme has been running for over ten years. I’ve helped over 400 patients in that time. Generally, people show an average weight loss of 11.8% in their first six months.
There’s roughly a three per cent fallout from those who do not continue the programme and we refer these people to their GPs if they were found to have high blood pressure or raised glucose levels.
This highlighted people who could need more help or those who have lost so much weight that they need to recalibrate their medicines – especially if they have diabetes, thyroxine, antipsychotics and painkillers.
Although I catch up with each patient monthly, my pharmacy’s door is always open and that’s where I measure statistical information, review the plan, emotional welfare, satiety and any salubrious anecdotes of patients.
I also note down any life-changing events and may even make a referral if necessary. Successes have included the great success of a lady who wore a bikini for the first time in over 20 years, a man who had been single for several years who managed to gain enough confidence to get into a relationship and people who were previously too tired to enjoy life but are now able to play with children and become more active.
I’ve had reports of people feeling good about themselves and wanting to also stop smoking and go to the gym. Others have stopped snoring, stopped sweating, especially at night, and generally have an improved quality of life. Others reduced medication, including using less painkillers.
I cannot over-emphasis the importance of access, motivation and inspiration as being key to any successful programme because that’s when patients need your help most and when they are at their weakest to keep going.