Are pharmacists equipped to deliver weight management services and, if so, what does a best-practice model look like?
Australia’s rising obesity rates place a significant burden on the public health system. Yet, through the provision of weight management services, there is the potential for community pharmacists to make a significant positive impact.
Australia ranks ninth of 36 OECD countries on obesity, with around 67% of the adult population considered overweight or obese. Despite the slowing pace at which obesity rates are rising, it’s essential to tackle this public health problem and promote healthier lifestyles.
Overweight and obesity is hugely detrimental to a person’s health and wellbeing. Carrying excess weight can increase the risk of cardiovascular disease, type 2 diabetes, some cancers and musculoskeletal disorders, among other serious diseases. Being overweight or obese is also a significant contributor to increased mortality.
From physical activity levels and diet to genes and hormonal changes, many factors can influence a person’s weight. However, overweight and obesity are, for the most part, preventable. The key is to achieve a balance between the calories consumed and calories spent.
Weight loss: the key points
- An estimated two in three (67%) Australians aged 18 and older are overweight or obese. This equates to approximately 12.5 million adults.
- The three essential elements of weight loss are dietary intake, exercise and behavioural change.
BMI is a practical tool for measuring and monitoring overweight and obesity.
- A person with a BMI of 25.0–29.9 is considered overweight but not obese. A BMI of 30.0 or above is classified as obese. A BMI greater than 35.0 is classified as severely obese.
- Pharmacotherapy can be considered in addition to behavioural therapy in people who are obese or in overweight people who have an obesity-related health issue.
- Where patients have undergone bariatric surgery, medication absorption and effectiveness should be considered, particularly if the person has a chronic disease.
Key elements in weight loss
Irene Um, lecturer at the University of Sydney School of Pharmacy, has conducted much research into weight management and the role of community pharmacy.
She told the AJP, “Best evidence still shows there are three key components regarding weight: dietary intake, physical activity and behavioural change. These are the elements first-line therapy should incorporate, with at least fortnightly follow up with a healthcare practitioner during the initial intensive treatment period (up to three months).
“Following on from this is when we can consider the addition of a product, whether that’s a meal replacement product or pharmacotherapy, such as orlistat or phentermine.
“As pharmacists, we’re really well placed to offer a weight management service as we act as a conduit to those important other services. We can provide advice at a general level and tailored to the individual. Where we see a person who would benefit from additional expertise, that’s when we can refer to allied healthcare professionals.
“However, a person might not necessarily follow-up with an allied healthcare professional as regularly as they would a pharmacist. So the pharmacist is in a prime position to provide the necessary follow-up action.
“We can make sure the individual is able to follow the dietician’s meal plan appropriately. We can also help identify any potential barriers the person is facing and refer back to the dietitian. Our role can be to ensure plans are followed, evaluated and reviewed.”
Elise Apolloni, pharmacist partner at Capital Chemist Group, says, “It’s important for pharmacists to have a general understanding of nutrition. In many cases weight loss can be achieved with simple dietary changes. It’s certainly okay to give advice on the dietary guidelines and how adhering to these could benefit the person’s health more widely.
“However, if a person believes they can’t achieve the goals they desire through diet and exercise changes alone, then it may be helpful to have a few different options. This might be life coaching, group exercise, a meal replacement program, or even different brands of OTC weight loss. It’s not about favouring one product or program over another, but understanding the person’s needs and finding a solution that will help them achieve their goal.
“Giving the consumer the choice is important. You might ask if they want to initially try changing their diet and incorporating an exercise plan; maybe you have an affiliation with a local gym or you’re able to direct them to free exercise groups in your area. If that doesn’t work or the person has more immediate goals, maybe you explore the in-pharmacy options.”
Pharmacy’s role: overcoming the barriers
“There seems to still be the misconception among consumers that a tablet or capsule will produce weight loss, and this is certainly an area pharmacists can work on. Weight management is a challenging topic, as consumers may not necessarily perceive pharmacists as able to give advice or counseling on weight loss, since we are suppliers of medicines,” says Ms Um.
If fact, a survey of 403 consumers from New South Wales showed that most of the participants considered pharmacists’ motivations to provide weight management advice related to gaining profit from selling a product and expressed concerns about the perceived conflicts of interest. Participants also perceived pharmacists as lacking expertise and time.
This study, along with others, shows the general public doesn’t necessarily recognise the extent of the pharmacists’ training and skills in regards to weight management. In spite of this, once they recognise the pharmacists’ ability in this area, the majority of people are willing to seek advice on this topic in the future.
“We often take a passive approach to advertising or promoting the services we have to offer, particularly in weight management. We might put up a sign or have a few posters on display, but perhaps we need to better explain to people what it is we have to offer,“ advises Ms Apolloni.
“In many cases, weight loss or weight management can be part of a bigger health solution. We know that people who have certain health conditions are more likely to have issues with weight or nutrition. For example, people with mental health concerns may not be looking after their nutrition as best they could.
There are many opportunities for us to raise the topic of weight or nutrition. It’s just about having a conversation with people and mentioning that you have a weight management service on offer,” she adds.
Ms Um says, “The positive news is that consumers do have confidence in pharmacists providing them with support, which is reassuring. I think tailored advice and action plans are important to show we can help people’s individual weight management needs.
“The information available online is often very generalised. Even if we look at something as simple as how to interpret a BMI score, there are limitations and it’s important to recognise what’s relevant to the individual and their circumstances. I think pharmacists can certainly play a role in providing this tailored advice.”
One of the most practical and useful tools in assessing a person’s weight is a Body Mass Index (BMI) calculator. While it is not diagnostic of the health of a person, it’s a simple way to categorise an individual’s weight.
The standard weight categories are as follows:
- Less than 18.5 = underweight
- 18.5–24.9 = normal/healthy weight
- 25.0–29.9 = overweight
- 30.0 and above = obese
Weighing in on weight loss
“Pharmacies are quite competent in terms of their knowledge and ability to provide appropriate recommendations based on the evidence available. Where we may need further training and development is in the confidence to approach individuals about this topic. There tends to be a stigma associated with talking about weight loss. There’s uncertainty about using appropriate language and how to be non-judgmental,” explains Ms Um.
“It’s always good to start by asking someone if they would be comfortable talking to you, as their community pharmacist, about their weight. This is quite a good non-judgmental, culturally appropriate and sensitive way to open up a conversation.
“There are a few possible avenues for pharmacists to engage people in conversation about weight management. The first is to run a dedicated health promotion, for example, a ‘know your BMI’ initiative.
“Secondly, if a person is looking at weight loss products you can be proactive and have a conversation with them before they select a product off the shelf.
“Lastly, if you’re dispensing a medication relating to a co-morbidity of obesity this presents a really critical opportunity to open up discussion. This is an intervention that pharmacists should involve themselves in.
After all, we are experts in medicine, so why not use this knowledge. Dispensing medicines is pharmacy 101, yet it’s probably not utilised as much as it could be in terms of interventions,” says Ms Um.
“We know that weight loss can dramatically decrease blood pressure, so if someone’s coming in with a prescription for blood pressure medicines and they’re overweight it may be appropriate to discuss weight management strategies,” says Ms Apolloni.
She adds, “It also helps when you share your own experiences, if relevant. As a mum myself, I know the difficulties of getting your body back in shape after having a little one. A lot of us have relevant experiences and we can be vulnerable and honest with people, which not only helps our customers to open up but it also incites trust.
“The other thing to consider is that it’s not always about weight loss; sometimes people simply aren’t eating a very nutritious diet and the weight management meal-replacement options that pharmacy can offer may provide a dietary benefit to the customer.”
Ms Um tells the AJP, “I believe weight management and health advocacy is a social responsibility for all health professionals. The problem of overweight and obesity has become so vast; it affects everyone. Yet, if we all do a little bit we can assist the health of our community.
“Pharmacists are very accessible and people do tend to visit their pharmacist regularly. It is these factors that put pharmacists in a good position to offer support. Even if someone achieves weight loss initially, maintaining that weight loss one or two years on is difficult. Pharmacists are ideally placed to provide that ongoing support and advice that’s crucial for successful long-term weight management.”
A new area for pharmacy: Bariatric surgery and medicines advice
“Bariatric surgery is not typically something that many pharmacists are familiar with. However, it’s becoming more common, so it’s potentially an area that pharmacists should look at building their confidence in,” says Irene Um.
While the Australian Institute of Health & Welfare (AIHW) lacks data relating to the past five years, it does reveal there were 22,700 hospital admissions for weight loss surgery in 2014-15 in comparison with 9300 in 2005-06.
Ms Um explains it’s important for pharmacists to consider the possible effects of bariatric surgery on medicine pharmacokinetics. We know it can decrease the absorption of some medicines. In which case, the patient may benefit from switching to a different formulation. For example, the person may switch from a solid dose to a liquid format or dissolvable tablet.
Other medicines, such as non-steroidal anti-inflammatory drugs, oral bisphosphonates and corticosteroids, can increase the risk of gastrointestinal irritation and ulceration following bariatric surgery.
Bariatric surgery can also affect a person’s nutritional status, potentially causing nutrient deficiencies—namely in iron, vitamin B12, thiamine, folate, calcium and vitamin D, which may necessitate continued supplementation.
Discovering a patient has undergone bariatric surgery presents an opportunity to provide advice on the pharmacokinetics of medicines, perform a medicines review and ensure adequate follow up and monitoring.
Ms Um says, “In terms of our role as dispensers of medicines, we can expect that medication changes will occur following bariatric surgery, so there’s certainly potential scope for pharmacists to play a greater role here.”