An open learning programme for pharmacists and pharmacy technicians Weight management Understanding the causes, prevention, assessment and management of obesity Educational solutions for the NHS pharmacy workforce DLP 134
Contents iii About CPPE open learning programmes ix About this learning programme xiii Supporting you, your practice and the NHS xvi Introduction why study this programme? xvii Section 1 Basics getting up to speed 1 Quiz: How much do you know? 1 1.1 Obesity in adults: how common is it? 4 1.2 How body weight is categorised 5 1.3 What is waist circumference? 6 1.4 How to measure body weight, height and 7 waist circumference Measuring body weight 7 Measuring height 8 Measuring waist circumference 9 1.5 Body fat percentage 10 Body fat meters 11 1.6 Obesity in children: how common is it? 12 1.7 How obesity is measured in children 12 Waist circumference 13 The National Child Measurement Programme 13 1.8 The causes of obesity 14 Food intake 14 Physical inactivity 15 Social and psychological factors 15 Economic factors 15 Other factors 15 1.9 The economic costs of obesity 16 1.10 The health burden of obesity 16 1.11 The beneficial effects of modest (10 kg) weight loss 17 1.12 Managing the growing problem of obesity 18 Government policies and national guidelines on 20 weight management Exercise 13 Practice points 6, 9, 10, 15, 18, 19
iv C O N T E N T S Summary and intended outcomes 21 References and further reading 22 Suggested answers 23 Section 2 Engaging with people 26 2.1 Improving the image of your pharmacy 26 2.2 Raising awareness of weight management 29 Raising the issue with individuals 30 Enhancing your communication skills for engaging with 32 customers 2.3 The stages of change theory 32 The precontemplative stage 33 The contemplative stage 33 The preparation (planning) and action stages 33 The maintenance stage 33 The relapse stage 33 2.4 Assessing a patient s readiness to change 34 Patient readiness checklist 36 Food diaries 36 Motivational interviewing 39 Neurolinguistic programming 42 2.5 Engaging with specific patient groups 44 Exercises 27, 29, 31, 34, 37, 40 Case studies 28, 37, 43 Practice points 28, 30, 35, 42 Summary and intended outcomes 45 References and further reading 47 Suggested answers 48 Section 3 Engaging with your local community about 53 weight management 3.1 Resources to help you to work with the wider community 53 Home 54 Schools 55 Workplace 56 Religious, community and social groups 56 Healthy eating campaigns 56
C O N T E N T S v Ways to minimise barriers to healthy eating 57 Leisure facilities 59 Local media 59 Exercises 57, 58 Practice points 54, 56, 59 Summary and intended outcomes 60 Suggested answers 61 Section 4 Diet 63 4.1 Healthy eating: what is it? 63 A word about alcohol 66 A word about water 68 A word about salt 69 4.2 Dietary energy requirements 69 Energy density 70 Portion size 72 Frequency of consumption 74 4.3 Choosing, buying, and cooking food 74 Shopping 74 Food labels 76 Cooking skills 78 Eating out 79 4.4 Popular diets 80 Low-carbohydrate diets 81 Carbohydrate-restricted diets 81 Detox diets 81 Food-combining diets 82 Single-food diets 82 GI diets 82 Low-fat, high-carbohydrate diets 83 Meal replacements 84 Very low-calorie diets 84 Internet diets 84 Which diet is best? 84 Exercises 66, 68, 71, 75, 76, 78, 79, 85 Case studies 85, 89, 90 Practice points 73, 74, 80
vi C O N T E N T S Summary and intended outcomes 90 References and further reading 92 Suggested answers 93 Section 5 Physical activity 102 5.1 What is physical activity? 102 The benefits of physical activity 103 5.2 The current recommendations for physical activity 104 Moderate-intensity physical activity 104 How the recommendations can be achieved 105 A note about pedometers 106 5.3 Facilitating physical activity 108 Exercises 103, 107 Case study 106 Practice point 106 Summary and intended outcomes 109 References and further reading 110 Suggested answers 110 Section 6 Role of drugs and surgery in weight management 112 6.1 Drug therapy 112 6.2 Anti-obesity drugs 113 Orlistat 113 Sibutramine 114 Rimonabant 115 How effective overall are anti-obesity drugs? 116 6.3 Surgery 116 Restrictive surgery 117 Malabsorptive surgery 118 Case study 119 Practice points 113, 116 Summary and intended outcomes 120 References and further reading 121 Suggested answers 122
C O N T E N T S vii Section 7 Over-the-counter slimming products and 123 complementary therapies 7.1 Over-the-counter slimming products 123 Ingredients used in over-the-counter slimming products 123 7.2 Complementary therapies 125 Practice points 125 Summary and intended outcomes 126 References and further reading 126 Section 8 Developing a weight management service 128 8.1 The community pharmacy contract 128 Essential services 128 Advanced services 129 Enhanced services 129 8.2 The elements of a pharmacy weight management service 129 8.3 Resources required to deliver a pharmacy weight 132 management service 8.4 Developing a business plan for a weight management 132 service Exercise 133 Case study 134 Practice point 131 Summary and intended outcomes 141 Suggested answers 142 Appendices Appendix 1. The Ashwell Shape Chart 144 Appendix 2. Resources and additional sources of information 145 Index 151
viii C O N T E N T S List of tables and figures Tables Table 1. Classification of body mass index 6 (white Caucasian adults) Table 2. Waist circumference and risk of cardiovascular disease 6 and/or insulin resistance (white Caucasian adults) Table 3. Co-morbidity risks associated with different levels of 7 BMI and waist circumference in Caucasian and Asian-Pacific populations Table 4. Typical calorie consumption for an adult woman 14 in the 1950s compared with the 2000s Table 5. Relative risks of health problems associated with 17 obesity in adults Table 6. The benefits of 10 percent weight loss 17 Table 7. Applying the stages of change model to assess a 35 patient s readiness to change Table 8. The calorific content of some popular alcoholic drinks 66 Table 9. The energy content of standard and large portion 73 sizes in the UK Table 10. Nutritional criteria for multiple traffic light labelling 77 Table 11. Guideline daily amounts for a typical adult 77 Table 12. Examples of the GI values of common foods 83 Table 13. Typical weekly chores and energy expended in the 102 1950s, compared with the 2000s Figures Figure 1. Trends in the prevalence of obesity in men and women 4 Figure 2. Waist circumference measurement 9 Figure 3. Body fat ranges for standard adults 11 Figure 4. Medical complications of obesity in adults 16 Figure 5. Stakeholders in weight management in England 19 Figure 6. The stages of change model 32 Figure 7. The eatwell plate model 64 Figure 8. Sources of energy in the British diet 70 Figure 9. Traffic light labelling 77 Figure 10. Guideline daily amount labelling 77 Figure 11. Adjustable gastric band procedure 117 Figure 12. Roux-en-Y type of gastric bypass procedure 118
About this learning programme xiii The overall aim of this programme is to encourage you and the whole pharmacy team, whether in the community, primary care, or in hospital, to contribute towards making obesity history, thereby improving the health of the nation. This will require the whole team to engage with the issues of weight management, and each member of the team will need to get their skills and knowledge up to date. Acquiring a broader knowledge of the subject area will enable pharmacies to promote appropriate public health messages about weight management. The pharmacy team will be able to develop their approach to include more proactive engagement with patients and customers, as well as working with, and influencing, the wider healthcare team. Target audience This programme is designed to help pharmacists, pharmacy technicians and pharmacy assistants ie, the whole pharmacy team in both community pharmacy, primary care, and hospital to discuss and competently integrate into their daily practice help for patients and customers in weight management as a key part of a patient-centred approach to healthcare. Learning style adopted in this programme This programme considers your potential role in a range of different circumstances, services and settings, and has been designed to provide you with the tools you will need to contribute to those services, as appropriate. You can work through the programme in its entirety or, if you prefer, use selected exercises, case studies and information to address specific learning needs that you have identified.
xiv A B O U T T H I S L E A R N I N G P R O G R A M M E Learning objectives CPPE has linked all its learning programmes to the Royal Pharmaceutical Society of Great Britain s competences for pharmacists and pharmacy technicians. This will make it easier for you to connect your professional practice to your learning needs and learning activities. We have selected only the competences for general pharmacists and pharmacy technicians, but we are aware that others exist. We have also linked the learning to the dimensions of the NHS Knowledge and Skills Framework (KSF). The competences and dimensions relevant to this programme are: Learning objectives RPSGB competences KSF dimensions Pharmacists Pharmacy technicians Understand the epidemiology of G1, G8 TG7 Health and well-being HW 6 Level 2 or 3 obesity in the UK. Information and knowledge (IK3) Level 1 Recognise the important role of G1 TG4 Quality Level 2 pharmacy in tackling the burden of obesity. Service improvement Level 2 or 3 Engage with staff, patients and G2 TG1 Communication Level 1 or 2 customers on the issue of weight management. Provide accurate healthy diet advice. G2, G6 TG5, TG12 Communication Level 1 or 2 Discuss the role of diet, physical G1, G7 TG5, TG7 Health and well-being HWB 6 Level 2 or 3 activity, medicines and surgery in the management of weight. Health and well-being HWB 7 Level 2 or 3 Appreciate the role of G7 TG6 Health and well-being HWB 7 Level 2 or 3 over-the-counter medicines and products in the management of weight. Describe the different pharmacy G5 TG3 Service improvement Level 2 service models providing weight management support.
A B O U T T H I S L E A R N I N G P R O G R A M M E xv Working through this programme This programme should take you approximately ten hours to work through, depending on your learning style and experience. Online resources Some of the references in this programme are to material that is only available online, and it is assumed that you will have access to a computer connected to the internet. If you do not wish to retype all the web addresses into your browser you may find it helpful to download this programme from the CPPE website as a PDF document containing live web links. Log on to: http://www.cppe.ac.uk Where we think it will be helpful we have provided the URL to take you directly to an article or specific part of a website. However, we are also aware that web links can change (eg, the Department of Health links) so in some cases we have provided the URL for the organisation s home page only. If you have difficulty accessing any web links, please go to the organisation s home page and use appropriate key words to search for the relevant item. Note on NICE guidance: To find any of the NICE guidelines or technology appraisals mentioned in this programme visit the NICE website at http://www.nice.org.uk On their home page, under Search NICE guidance, enter the relevant topic and click Search. Note on articles: If you have difficulty locating an article on the internet, search via: http://www.google.co.uk by typing in the title, author, date and name of the journal. It can also be helpful if you add in, at the end of the search criteria, the website you think the information is on, eg, dh.gov.uk
xvi Supporting you, your practice and the NHS When devising this programme we paid special attention to how it would contribute both to your own professional development and to the overall improvement of NHS services. We have illustrated some of these benefits in the diagram below (you will find more detail as you progress through the programme). Community pharmacy You will be able to develop a protocol for weight management for use by the pharmacy team. Pharmacist prescribing Weight management services could be expanded using the skills of pharmacist prescribers. Policy drivers This learning supports numerous health initiatives such as Choosing health and Choosing health through pharmacy, the community pharmacy contract and the GMS contract, including the quality outcomes framework (QOF). You, your practice and this learning programme Evidence-base/guidelines This programme supports national guidelines provided by: Department of Health Faculty of Public Health National Obesity Forum (NOF) NICE Supporting skill mix This programme will show you how the whole pharmacy team can be involved in helping people with weight management.