National Public Health Service for Wales
Weight management/community pharmacists
Weight management
interventions by community
pharmacists: a rapid review
of the evidence
Author: Dr Mary Webb, Public Health Practitioner
Date: 11/02/2009
Version: 1.a
Status: Final
Intended Audience: LHB Heads of Pharmacy and Medicines Management
Purpose and Summary of Document:
The NPHS (pharmaceutical public health team) has been commissioned by
the Welsh Assembly Government to develop pharmaceutical needs
assessment tools. This work is in the context of the community pharmacy
contractual framework in Wales.
This rapid review of the evidence was produced in order to inform the
development of a pharmaceutical needs assessment tool for the delivery of
weight management interventions by community pharmacists in Wales. This
report should be read in conjunction with other relevant documents on the
pharmaceutical public health team document database.
Publication/Distribution:
 Distribution to NPHS pharmaceutical public health team, Welsh
Assembly Government, LHB Heads of pharmacy and medicines
management
 Publication on the NPHS internet and intranet websites
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
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Status: Final
Intended Audience: Pharmaceutical
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National Public Health Service for Wales
Weight management/community pharmacists
Table of contents
1.
Executive Summary .................................................................................. 3
2.
Introduction ............................................................................................... 4
3.
Aims .......................................................................................................... 4
4.
Methods .................................................................................................... 5
5.
4.1
Systematic searching......................................................................... 5
4.2
High level searching .......................................................................... 5
4.3
Inclusion Criteria ................................................................................ 6
Results ..................................................................................................... 6
5.1
Clinical guidelines/guidance recommendations ................................. 9
5.2
Barriers to implementation in community pharmacies ..................... 10
5.3
UK community pharmacy weight management services. ................ 11
5.4
Cost-effectiveness ........................................................................... 12
6.
Conclusions ............................................................................................ 13
7.
References ............................................................................................. 14
Appendix 1
Search terms and results ...................................................... 17
Appendix 2
Evidence levels and quality grading ...................................... 18
Appendix 3
Evidence table ...................................................................... 19
Appendix 4
Components of weight management programmes ............... 26
© 2009 National Public Health Service for Wales
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to the National Public Health Service for Wales to be stated.
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 2 of 28
Status: Final
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1.
Weight management/community pharmacists
Executive Summary
There is general consensus that obesity is becoming a major public health
challenge and effective measures are urgently needed to address the
problem. The pharmacy profession is increasingly recognising that it can play
an important role in the new public health agenda.
Community pharmacists (CPs), through the Community Pharmacy
Contractual Framework, now take part in health promotion campaigns and
some offer enhanced services such as weight management.
Before
commissioning such services it is essential to assess the evidence base for
the clinical and cost effectiveness of such services.
The aim of the present document was to perform a rapid review of the
evidence on the effectiveness of CP led weight management interventions.
The literature searches did not identify any good quality (Level 1 or Level 2)
evidence to support the effectiveness of CP weight management
interventions. There was one small randomised controlled trial performed in
the United States with short follow-up that demonstrated a weight loss.
There were however, several good quality literature reviews that were used to
inform the present paper. These reviews identified four Level 3 studies, from
which the evidence from Levels 3/4 was suggestive that weight loss does
occur in individuals participating in the weight loss programmes; none of the
studies were from the United Kingdom.
There was considerable UK national guidance recommending the involvement
of CPs in weight management.
There was some evidence to indicate which interventions should be included
in weight management programmes delivered by CPs and how to address the
barriers to successful implementation. The evidence suggested that such
programmes should include advice on lifestyle change, physical activity,
behaviour modification and support to the client. Drug treatment in conjunction
with lifestyle change may be required for some individuals.
There are a considerable number of CP led weight management programmes
being undertaken within the UK, but comprehensive evaluation data was not
found.
Author: Dr Mary Webb, Public Health
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Status: Final
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2.
Weight management/community pharmacists
Introduction
The detrimental effects of obesity on health are well known, yet despite
preventative methods its incidence is continuing to rise. Managing the
problems caused by this issue has involved a range of health professionals,
including doctors, dieticians, exercise physiologists, physiotherapists and
psychologists.
Over the last decade community pharmacy (CP) has been undergoing a
paradigm shift in the focus of its practice. Community pharmacists have
extended their role from dispensing medicines to providing a broad range of
cognitive interventions through enhanced pharmacy services (EPS). With
regard to obesity the question being debated is, can CPs provide a weight
management EPS that could be integrated with the healthcare system and
help treat overweight clients.
The White Paper Pharmacy in England highlighted the UK government’s
desire for pharmacists to provide weight management services to the public. 1
A recent survey across Europe indicated that the pharmacy profession is
increasingly recognising the potential to be involved in weight management. 2
There is however controversy about the evidence in relation to whether
pharmacy-run weight management services are effective in helping to solve
the obesity epidemic. 3 As part of the on-going programme of pharmaceutical
needs assessments (PNAs) led by the NPHS Pharmaceutical Public Health
Team, the Local Health Boards in Wales were asked to prioritise topics for
NPHS supported PNAs. The leading topic for development into a PNA during
2008/09 was weight management. Information was then required on which
interventions that could be delivered by CPs are effective in promoting weight
loss.
3.
Aims
The purpose of the present document is to report the results of a rapid review
of the evidence for the effectiveness of weight management interventions
delivered by CPs.
Author: Dr Mary Webb, Public Health
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4.
Weight management/community pharmacists
Methods
Existing and ongoing research was identified through literature searching.
4.1
Systematic searching
As per the protocol contained in The Evidence Checklist 4 a scoping search
was initially performed to identify major papers on published evidence and
refine the final search strategy. For the present overview, search terms
contained in the search strategies were used from published reviews and they
were kept broad to maximise retrieval of references. The basic search
strategy is shown in Appendix 1.
The type of literature on weight management interventions in CPs
necessitated the use of a pragmatic approach to searching for evidence in
order to achieve production of the review, within the short timescales for
delivery. It is clear that there had to be a balance between timeliness and
rigour and high quality evidence and systematic reviews, meta-analyses,
health technology assessments and clinical guidelines were identified first. It
should be emphasised that the review is not a systematic review of primary
studies.
4.2
High level searching
It is well known that the classical databases for medical literature, such as
Medline, do not adequately index all relevant literature. The reviewer used
previously described validated methods that involved the use of meta-search
engines and other databases for ‘high level’ searching to quickly identify
relevant evidence.
For critical appraisal, the tables recommended for use in the National Institute
for Health and Clinical Excellence guideline development methods manual 5
were modified to accept the type of studies identified for community
pharmacy/ies/ists and weight management interventions. The quality of the
evidence was graded using the NICE hierarchy of evidence and the quality
checklists. Evidence was rejected if graded as poor quality, apart from where
it was of Level 1 type (see Appendix 2 for explanation of evidence grading
system) and was highly relevant to the questions.
The data relevant to the research question was entered into an evidence
table. (Appendix 3) Due to practical limitations a single reviewer performed
the final selection, critical appraisal and data extraction.
Author: Dr Mary Webb, Public Health
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4.3
Weight management/community pharmacists
Inclusion Criteria
Search period January 2004 – December 2008
Papers in English, German, French or Spanish
Papers relating to the effectiveness of weight reduction interventions for
adults by CPs/community pharmacies
Randomised controlled trials
Systematic reviews
Meta-analyses
Guidelines
Observational studies (where higher quality evidence was not available)
5.
Results
The scoping search revealed several up-to-date comprehensive reviews of
the evidence for the effectiveness of CPs in improving public health that
included weight management interventions. The Royal Pharmaceutical
Society of Great Britain (RPSGB) had also published a comprehensive list of
references on CPs and weight management interventions. 6
The results of the systematic search are shown in Appendix 1. There were a
large number of hits for CP services and weight and date limits and
publication type limits were applied, followed by filters for systematic
reviews/reviews and randomised controlled trials (RCTs).
High level searching indicated several relevant documents that were not
indexed in the classical databases such as Medline and Embase and illustrate
the problems with retrieval of evidence.
The authors of two reviews covering the period 1990 to 2004 of both
international peer reviewed and non-peer reviewed literature on community
pharmacy’s contribution to improving public health concluded that the strength
of the evidence base for CP interventions was poor. 7, 8 The reviews included
only two studies for weight management by CPs, one observational study
(Level 3) from Denmark and a RCT (Level 1-) from the United States (US).
The Danish study 9 reported the results of slimming courses held at 19 CPs
for 269 overweight clients. The average self reported weight loss was 5.3kg
for women and 6.2kg for men and at 1 year, 20% of clients who completed the
course had maintained the weight loss; problems with self reporting are well
known. The trial from the US 10 randomised patients to a meal replacement
(MR) or reduced calorie diet (RCD) plan. The programme involved three
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weekly visits to the CP and 88 participants who attended at least one follow
up visit were included in the analysis. Follow up was 3 months for weight
reduction and 10 weeks for weight management. Improvements in weight
loss occurred and were similar for both the MR and RCD plans and were
maintained during the follow up period.
The third review from the same group published in 2008, 11 found six relevant
studies that involved weight management, three of which involved the use of
interventions; all the studies were of Level 3 type evidence. A service
provided in a single pharmacy in the US resulted in a mean weight loss of
3.6kg among 216 people over a mean duration of 26 weeks. 12 The service
involved an initial consultation with the pharmacist (scheduled for 1.5 hours)
followed by 15 minute fortnightly follow ups until target weight was reached
and then a three monthly follow up. The service was provided free during the
study period and is now offered on a fee-paying basis.
In a Swiss study, 3800 people who had participated in CP-based screening
for diabetes were asked to take part in a programme of lifestyle counselling.
Of the 1370 who took part, the mean weight loss was 0.6–1.9 kg at 3 months.
People in the high-risk counselling group (245) showed weight loss of 2.25%
at 3 months and 2.74% at 1 year. 13
The study reported by John et al. 2006, 14 in which CPs provided education
about cardiovascular disease, identification of drug therapy problems, and the
importance of routine blood pressure, pulse, and weight measurement in a
workplace health-improvement programme did not find a significant effect on
weight. This study however, included only 56 patients of which 37 had
diabetes.
An extensive study into developing an evidence based CP weight
management project was performed in Australia.15
Evidence for the
effectiveness of the various components was assessed and the details are
described in Appendix 4. The evidence indicated that all successful weight
management programmes involve some form of lifestyle change either on
decreasing energy intake or increasing energy expenditure or both. Behaviour
modification and support to the client, some medications, a very low energy
diet or surgery may also aid treatment. 16
There is national guidance on drug treatments for obesity in England and
Wales.17 Adding drug treatment to lifestyle approaches may be considered
for individuals who have not reached their target weight loss, or for those who
have reached a plateau with dietary, physical activity and behavioural change
interventions. Drug treatment may be considered for overweight people who
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have co-morbidities or for people without co-morbidities who have a BMI ≥
35kg/m2. The evidence for the effectiveness of anti-obesity drugs in addition
to lifestyle changes indicates that patients lose an average of approximately
3-5kg more weight than with placebo in the first year.17 Continuing treatment
into a second year helps to maintain the weight loss. There was however a
lack of good quality evidence on long term effectiveness. 18
There are also many complementary therapies that claim to be effective for
reducing weight that can be purchased over-the-counter. A systematic review
that assessed the evidence for their effectiveness in reducing body weight
was published in 2005. Six systematic reviews and 25 additional RCTs were
reviewed. The evidence considered was from studies of acupuncture,
acupressure, dietary supplements, homeopathy and hypnotherapy. There
were small effects for hypnotherapy and ephedrine containing dietary
supplements, but for the other treatments evidence was lacking. The intake
of ephedrine containing compounds is however associated with an increased
risk of adverse events. 19
Of relevance to the role of CPs in weight management was the literature
review published by Brown20 on the management of obesity in primary care by
nurses. Eleven studies were reviewed, two of which examined outcomes
following attempts to implement evidence based protocols. The evidence of
positive outcomes was inconsistent and the maximum number of patients that
achieved a clinically significant weight loss was only 10%.
A toolkit has recently been published by the Faculty of Public Health to
provide further support for developing a local strategy to tackle overweight
and obesity.21 It is primarily aimed at commissioners of public health services
in primary care trusts (PCTs) and local authorities. It contains an assessment
of the evidence for which interventions to choose and the rationale behind
involvement of pharmacists. The conclusions for the role of CPs are based
on two documents 18, 22 and are: Outline role of pharmacists in promoting health weight



provision of physical activity leaflets and information issued with
prescriptions
opportunistic advice on physical activity
signposting to local physical activity opportunities
 Personalised advice and support from pharmacists

provision of healthy living advice
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

Weight management/community pharmacists
referral to local weight management services
delivery of weight management services or brief interventions where
appropriate.
The toolkit also stated that it remains unclear whether the source of delivery
(both of the main intervention and ongoing support) has an influence on
effectiveness and that none of the identified studies considered inter-agency
or inter-professional partnerships.
5.1
Clinical guidelines/guidance recommendations
The RPSGB produced a practical guide on public health for CPs, the aim of
which was to determine which health development activities are most likely to
be effective in a CP setting.23 The evidence from the published literature, both
peer reviewed and grey literature was that further research is needed before
conclusions can be made about the effectiveness of CP led programmes.
The evidence for the contribution of pharmacy to improving health was also
reviewed for the publication from the Department of Health “Choosing health
through pharmacy” 22. The authors concluded that there was a strong
evidence base for brief consultations on health behaviours linked to PCTs
public health programmes. Brief consultations were not defined and despite
considerable interest in the effectiveness of brief interventions delivered in
primary care, there was a lack of good quality evidence to support their role in
weight reduction or management.18 There was also some evidence that
healthy eating programmes based in pharmacies are effective, if appropriate
evaluation for weight reduction is carried out.22 The authors proposed a care
pathway to be delivered by CPs:Raise awareness and provide information
↓
Raise the issue opportunistically and provide advice
↓
Refer as appropriate to specialist services,
e.g. diet, physical activity, drugs, surgery
↓
Review and maintain progress
A national clinical guideline on the prevention and management of obesity
was published in 2006 by the National Institute for Health and Clinical
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Excellence. 18 In relation to the pharmacy profession, a number of roles were
identified in relation to pharmacy. The guideline recommends: If someone has concerns about weight or diet then they should discuss
these with a pharmacist.
 With specific training, staff such as pharmacy assistants or support
staff in general practices may also be able to give advice and support.
 Multi-component interventions are the treatment of choice. Weight
management programmes should include behaviour change strategies
to increase people’s physical activity levels or decrease inactivity,
improve eating behaviour and the quality of the person’s diet and
reduce energy intake.
 The decision to start drug treatment, and the choice of drug, should be
made after discussing with the patient the potential benefits and
limitations, including the mode of action, adverse effects and
monitoring requirements and their potential impact on the patient’s
motivation. When drug treatment is prescribed, arrangements should
be made for appropriate health professionals to offer information,
support and counselling on additional diet, physical activity and
behavioural strategies. Information about patient support programmes
should also be provided.
5.2
Barriers to implementation in community pharmacies
The attitude of pharmacists towards providing weight management services is
an important factor in their successful implementation. There appeared to be
very little published literature on this, but new data from a survey of 350
pharmacists in Europe, that included the UK, indicated that the pharmacy
profession is increasingly recognising the potential to be involved in weight
management. Ninety-six percent of the relatively small sample surveyed
showed that the pharmacists in Europe believed that with support and training
they are well placed to help people with their weight loss efforts. Ninety two
percent thought that they should give advice on behavioural change, whilst
90% thought that that guidance on healthy eating should be provided; 74%
thought that they should offer advice on drug therapy for weight loss. 24
A recently published report 25 shows that across Europe, 64% of people (out
of a total of over 6,000 questioned in six countries) agreed that CPs should be
developed as alternatives to doctors' clinics, so that they can have more
choice in getting advice and treatment for common conditions. Support for
extending pharmacy based health care was strongest in the UK and Poland.
Over 75% of people in both countries supported the further development of
pharmacies as alternatives to doctors' clinics.
Author: Dr Mary Webb, Public Health
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One review of the literature15 indicated that CPs are willing, but perhaps not
always able to provide EPS and the major barriers to EPS have been
identified by a number of studies. The evidence suggested that the
capabilities of CPs to provide a weight management programme will be
negatively affected by the following:






5.3
The cost of running the EPS - remuneration for the CP to undertake
this EPS must cover the additional workload involved. This improves
the likelihood of the program being adopted, implemented, and
sustained in CPs
Workload and personnel shortages,
Accreditation: skill set, support and training,
Facilities and staffing,
Ethical barriers,
Professional relationships and boundaries.
UK community pharmacy weight management services.
There are many CP initiatives that are being undertaken in the UK and further
details and links to publication details can be found in the RPSGB’s 2008
publication.6 The Coventry PCT obesity management project was set up in
March 2007 and the perceived success of the project was one of the major
driving forces behind the recommendation in the Department of Health’s
recommendation 1 that CPs should be involved in weight management
services. In the project the patients would have a consultation with the
pharmacist on a regular basis to discuss achievable and maintainable lifestyle
goals. Ten pharmacies in Coventry took part in a pilot scheme for one year
and recruited 160 obese patients identified as being at risk of developing longterm illnesses. The scheme helped 34 patients lose a total of 130kg.
Pharmacy contractors were paid £20 for each initial patient consultation and a
further £15 for each follow up consultation. It is estimated that the total cost
per patient is £200. Between March 2007 and September 2007, 80% of
adults (n= 140) on the programme had lost on average 5% of their body
weight.
The Healthy North Ayrshire project consists of the provision of health checks
by CPs for people with risk factors for cardiovascular disease and has been
running from April 2006. Evaluation of the project is currently being
performed.
One large pharmacy multiple offers weight loss services aimed at individuals
with a Body Mass Index (BMI) of ≥ 28. The services consist of an initial
Author: Dr Mary Webb, Public Health
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consultation and assessment with a pharmacist, and where appropriate, the
supply of an effective1 weight loss medicine, reviews and discounts on related
products.
A pilot weight reduction service was set up in a community pharmacy in
Swansea in 2004. A preliminary communication was published, but no further
publications were revealed by the search.
5.4
Cost-effectiveness
No cost-effectiveness studies of relevance to CP led weight management
programmes in the UK were found. The authors of the NICE obesity
guideline18 commented on the lack of evidence on the cost effectiveness of
any interventions for weight management, partly because of a lack of outcome
measures that are amenable to health economic evaluations. Much of the
evidence on the effectiveness of prevention strategies concerns crude
measures such as average weight loss rather than response rates, and
follow-up periods are usually short-term.
More information is required from quality-of-life questionnaires throughout the
intervention and follow-up period and this would help assess the value to the
individual of any clinical improvement. This would allow greater comparison
between types of intervention and improve the assumptions that need to be
made in any cost-effectiveness analyses.
1
There is no mention of the evidence for this
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6.
Conclusions

There was a lack of consistent good quality Level 1 and Level 2
evidence on the effectiveness of CP led weight reduction/ management
interventions.

The results from a small number of observational studies performed
outside of the UK provide some support for the role of CPs in weight
management.

There are national guidelines/guidance recommending the involvement
of CPs in helping individuals to lose weight.

There is some evidence to indicate what interventions should be
provided by CPs for effective weight loss and management and how to
ensure successful implementation.

Overweight and obesity are issues related to inequalities, and CPs are
particularly well located to assist with weight management, as many of
them are based close to residential areas and have few physical and
psychological barriers related to access.

The problem with all the available CP programmes in existence in the
UK is the lack of published data on comprehensive evaluation of
clinical and cost-effectiveness.
New and existing interventions
delivered by CPs need to be properly evaluated in the light of current
and emerging evidence.

There is also a need for research evaluating multi-component/
multiagency interventions to manage obesity in primary care, because
factors such as the types of participant, the training of staff and the
availability of resources may affect the results.

The latest publication from the Faculty of Public Health, containing a
toolkit with details on how to provide further support for developing a
local strategy to tackle overweight and obesity, states that “local areas
should not feel constrained by the lack of evidence on effectiveness.
The evidence base will only improve if new methods are tried and
evaluated properly”.
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7.
Weight management/community pharmacists
References
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[Accessed 2nd December 2008]
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m
[Accessed 2nd December 2008]
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http://www.pharmacyhealthlink.org.uk/files/Evidence%20Base%20Report%20
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(12) Lloyd KB et al. Implementation of a weight management pharmaceutical
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(13) Botomino A et al. Change of body weight and lifestyle or persons at risk
for diabetes after screening and counselling in pharmacies. Pharmacy World
& Science. 2007; Nov 29 (Epub ahead of print)
(14) John EJ et al. Workplace-based cardiovascular risk management by
community pharmacists: impact on blood pressure, lipid levels and weight.
Pharmacotherapy 2006; 26:1511.
(15) Rieck A, Clifford R, Everett A. Community pharmacy weight
management project. Stages one and two (2005-2002). Perth; University of
Western Australia; 2005. Available at:
http://www.guild.org.au/uploadedfiles/Research_and_Development_Grants_P
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December 2008]
(16) National Health and Medical Research Council. Clinical practice
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(17) National Prescribing Centre. The drug management of obesity. MeReC
Bulletin 2008; 5:1.
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(18) National Institute for Health and Clinical Excellence. Obesity: guidance
on the prevention, identification, assessment and management of overweight
and obesity in adults and children. CG 43. London: NICE; 2006. Available at
http://www.nice.org.uk/Guidance/CG43 [Accessed 2nd December 2008]
(19) Pittler MH, Ernst E. Complementary therapies for reducing body weight:
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(20) Brown I; Psarou A. Literature review of nursing practice in managing
obesity in primary care: developments in the UK. J Clin Nurs 2007; 17: 17
(21) Swanton K. Health weight, healthy lives; a toolkit for developing local
strategies. London: Department of Health, National Heart Forum; 2008.
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_088968
[Accessed 2nd Dec 2008]
(22) Department of Health. Choosing health through pharmacy. A
programme for pharmaceutical public health 2005–2015. London: DH; 2005.
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPo
licyAndGuidance/DH_4107494
[Accessed 2nd December 2008]
(23) Royal Pharmaceutical Society of Great Britain. Public health; a practical
guide for community pharmacists. Available at:
http://www.rpsgb.org.uk/pdfs/pubhlthguidcommph.pdf [Accessed 2nd
December 2008]
(24) ICM Research. Survey among 350 pharmacists in Europe, across
Czech Republic, Germany, France, Poland, Slovakia, Switzerland and the
UK. ICMR; 2008. Cited in reference 2
(25) The School of Pharmacy, University of London. Greater expectations.
Pharmacy based health care – the future for Europe? London: University of
London; 2007. Available at:
http://www.pharmacy.ac.uk/fileadmin/documents/News/Greater_Expectations
_web_edition.pdf [Accessed 2nd December 2008]
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 16 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
National Public Health Service for Wales
Appendix 1
Weight management/community pharmacists
Search terms and results
The following terms were used to search Ovid Medline, Embase, Cochrane Database
of Systematic Reviews, ACP Journal Club, EBM reviews, Database of Abstracts of
Reviews of Effects; Cochrane Central Register of Controlled Trials; British Nursing
Index and Cinahl, and HMIC:
‘Services, pharmaceutical and weight control; services, pharmaceutical and obesity;
pharmacist and weight control; pharmacist and obesity; community pharmacy and
weight control; community pharmacy and obesity, obesity/prevention and control;
obesity/therapy; individualised; value; expertise; primary care; pharmacy; public
health; obesity, overweight, treatment/therapy, treatment efficacy, behaviour therapy,
pharmacotherapy, cognitive behaviour therapy, meta analyses, systematic reviews,
attitudes, incentives, gender issues, obesity management, weight management,
commercial weight management, weight loss, commercial weight loss programmes,
commercial slimming programmes’.
SEARCHES
RESULTS
1
pharmacists.mp. [mp=ti, ot, ab, hw, nm, sh, tn, dm, mf]
21068
2
community pharmacy.mp. [mp=ti, ot, ab, hw, nm, sh, tn, dm, mf]
2505
3
community pharmacy services.mp. [mp=ti, ot, ab, hw, nm, sh, tn,
dm, mf]
1136
4
pharmacies.mp. [mp=ti, ot, ab, hw, nm, sh, tn, dm, mf]
7820
5
pharmaceutical services.mp. [mp=ti, ot, ab, hw, nm, sh, tn, dm,
mf]
5639
6
((#1 or #2 or #3 or #4 or #5) and health education).mp. [mp=ti, ot,
ab, hw, nm, sh, tn, dm, mf]
25032
7
(#1 or #2 or #3 or #4 or #5 health promotion).mp. [mp=ti, ot, ab,
hw, nm, sh, tn, dm, mf]
7902484
8
(#1 or #2 or #3 or #4 or #5 public health).mp. [mp=ti, ot, ab, hw,
nm, sh, tn, dm, mf]
7902488
9
(pharmac* and diet).mp. [mp=ti, ot, ab, hw, nm, sh, tn, dm, mf]
10411
10
(pharmac* and body weight).mp. [mp=ti, ot, ab, hw, nm, sh, tn,
dm, mf]
11789
11
limit 10 to yr="2004 - 2009"
4746
12
limit 9 to yr="2004 - 2009"
4883
13
limit 8 to yr="2004 - 2009"
2947613
14
limit 6 to yr="2004 - 2009"
10788
15
limit 13 to "core clinical journals (aim)" [Limit not valid in
EMBASE; records were retained]
16
limit 15 to latest update
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
1465718
5150
Date: 11/02/2009
Page: 17 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
National Public Health Service for Wales
Appendix 2
Weight management/community pharmacists
Evidence levels and quality grading
(modified from NICE Guideline Methodology Manual)
Level of Evidence
1++
1+
12++
2+
2-
3
4
Type of evidence
High-quality meta-analyses,
systematic reviews of RCTs, or
RCTs with a very low risk of bias
Well-conducted meta-analyses,
systematic reviews of RCTs,or RCTs
with a low risk of bias
Meta-analyses, systematic reviews of
RCTs, or RCTs with a high risk of
bias
High-quality systematic reviews of
case–control or cohort studies. Highquality case–control or cohort studies
with a very low risk of confounding,
bias, or chance and a high probability
that the relationship is causal
Well-conducted case–control or
cohort studies with a low risk of
confounding, bias, or chance and a
moderate probability that the
relationship is causal
Case–control or cohort studies with a
high risk of confounding bias, or
chance and a significant risk that the
relationship is not causal
Non-analytic studies (for example,
case reports, case series)
Expert opinion, formal consensus
Quality grading
++ = good quality
+
= fair
+/- = fair to poor
- = poor
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 18 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
National Public Health Service for Wales
Appendix 3
Weight management/community pharmacists
Evidence table
STUDY
POPULATION/
SETTING
INTERVENTION/AIM
OUTCOMES
RESULTS
Ahrens RA, Hower M, Best
AM. Effects of weight
reduction interventions by
community pharmacists.
Journal American
Pharmaceutical
Association 2003; 43: 583
(Reference 10)
Adults attending a CP.
To compare a meal replacement
programme with a conventional RED
for weight management using the
pharmacy as the setting and the
pharmacist as the point of contact for
dietary advice.
Meal replacement (MR): n = 45.
BMI (kg/m2): 29.5 (SD 2.2)
Weight (kg): 81.9 (SD 11.1)
Waist circumference (cm): 89.1
(SD 8.5)
Age (years): 47.6 (SD 7.9)
Participants received free liquid meal
replacement shakes (Slim-Fast) and
were instructed to use these to
replace two main meals per day for
the first 12 weeks, and one main meal
a day for the following 10 weeks.
They were also given dietary advice
involving instruction on healthy
eating, the prescription of a daily
energy intake in the first 12 weeks
and assistance in self-selecting the
rest of their diet. Participants were
given physical activity (PA) advice at
their initial visit. They returned to the
pharmacy every 2 weeks for a 15 min
review to discuss progress and to
collect their shakes.
Weight loss/
weight
maintenance
Length of followup =
12 and 22
weeks.
Weight (kg):
Over the 12-week
intervention period,
weight decreased
significantly (p <
0.001) in both MR (–
4.9 [SE 0.3]) and
RED (–4.3 [SE 0.3])
groups. There was no
significant difference
between the two
groups.
Participants were
required to be free of
specific medical
conditions and have a
BMI of 25–32 kg/m2.
US
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 19 of 28
During the weight
maintenance phase,
from week 12 to
week 22, there was a
significant (p = 0.02)
further loss in the
RCD group (–0.9 [SE
0.4]). The change in
the MR group (–0.7
[SE 0.4]) was not
statistically
significant. There was
no significant
difference between
the two groups.
Loss to follow-up:
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
COMMENTS
Italics=
reviewers
comments
Ninety-five
participants
(12.6% male)
were randomised
but data are only
provided for
participants who
remained in the
programme at
week 2
This is the only
significant RCT
of CP
intervention
revealed by
search. The
primary outcome
was to compare
two methods of
producing weight
reduction/weight
management.
DESIGN
EVIDENCE
LEVEL/
QUALITY
RCT
1-
+
National Public Health Service for Wales
Weight management/community pharmacists
Delivered by:
A registered dietician reviewed diet
plans and was consulted as needed.
Two pharmacists provided all other
support. The pharmacists received no
special training.
Conventional reduced-energy diet
(RED):
n = 43
BMI (kg/m2): 29.0 (SD 2.6)
Weight (kg): 78.3 (SD 10.1)
Waist circumference (cm): 87.0
(SD 8.2)
Age (years): 47.8 (SD 9.5)
Participants were given dietary advice
involving instruction on healthy
eating, the prescription of a daily
energy intake and assistance in selfselecting their diet using diabetic
exchange lists. After 12 weeks they
were instructed to return to a healthy
diet of their choice. Participants were
given the same PA advice and
support as the intervention group.
12-week intervention:
n = 27/95 (28%)
Weight maintenance:
n = 40/95 (42%)
Not reported for
individual groups.
Delivered by:
As intervention group.
Botomino A et al. Change
of body weight and lifestyle
of persons at risk for
diabetes after screening
and counselling in
pharmacies. Pharmacy
World & Science. 2007;
Nov 29 (Epub ahead of
print). (Reference 13)
Nation wide diabetic
campaign. Individuals
> 18 years old, BMI of
≥25 and > 1 risk factor.
Switzerland.
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Investigation of pharmacy based
counselling on lifestyle changes and
body weight.
Sample stratification: 1400 at
moderate risk for diabetes received
standard counselling (SC) in the
pharmacy; 1500 ( moderate diabetes
risk) received intensive counselling
(IC) and 900 at high risk (HRC).
Date: 11/02/2009
Page: 20 of 28
Differences in
average BMI &
weight,
percentage of
weight loss,
percentage of
subjects able to
lose ≥5% of
initial body
All counselling
groups ( SC; n=557,
IC; n= 568, HRC;
n=245) showed
significant weight loss
at 3 months. The
HRC group showed a
higher weight loss
than the IC or SC
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
The authors
discuss the
possible
limitations of their
study- high drop
out rates,
problems with
self reported
data, responder
Qualitative
survey
3
+
National Public Health Service for Wales
Weight management/community pharmacists
Pharmacists were trained for
counselling on risk factors in 2
obligatory evening courses.
Questionnaires were sent at 3, 9, and
15 months.
Brown I; Psarou A.
Literature review of nursing
practice in managing
obesity in primary care:
developments in the UK. J
Clin Nurs 2007; 17 : 17.
(Reference 20)
Department of Health.
Choosing health through
pharmacy. A programme
for pharmaceutical public
health 2005-2015. London:
DH; 2005
(Reference 22)
Literature review
Review of literature on primary care
nursing practice to manage obesity.
weight & self
reported change
in diet and
exercise.
Assessed the
%age change
with physician
contact
compared with
CP contact.
-
Global
Strategy document for
pharmacists in all NHS
sectors on
interventions to
improve public health.
A review of the evidence for the
effectiveness of CP in improving
public health.
UK
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 21 of 28
-
group at 3 months.
bias.
11 studies were
identified. The
interventions could
be categorised as
general oral advice
about nutrition and
lifestyle. There was
no evidence of
positive outcomes
from these
interventions. In
some cases advice
was combined with
calorie deficient diets
and referral to
physical activity and
there was mixed
evidence on a
positive effect.
Evidence was
considered to be
good for brief
interventions by CPs
on health behaviours
that were linked to
PCT public health
programmes and for
healthy eating
The methods
used by nurses in
the community
are applicable to
CP led
interventions.
The fact that a
maximum of only
10% of patients
achieved a
significant weight
loss is a
cautionary note
for any CP led
intervention and
needs further
investigation
Literature review
The care
pathway
proposed in the
document lacks
detail and the
conclusion on the
evidence for brief
interventions is
controversial
Review/expert
opinion
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
2++
+
3/4
+
National Public Health Service for Wales
John EJ et al. Workplacebased cardiovascular risk
management by
community pharmacists:
impact on blood pressure,
lipid levels and weight.
Pharmacotherapy 2006;
26:1511
(Reference 14)
Workplace
Lloyd KB et al.
Implementation of a weight
management
pharmaceutical care
service. Ann Pharmacother
2007;41:185–92.
(Reference 12)
Pharmaceutical care
centre in US university
campus
National Health and
Medical Research Council.
Clinical practice guidelines
for the
Management of overweight
and obesity in adults.
Canberra: Department of
Health and Ageing; 2003
(Reference16)
National Institute for Health
and Clinical Excellence.
Obesity: guidance on the
prevention, identification,
assessment and
management of overweight
Clinical guideline for
obesity
US
Weight management/community pharmacists
Assessment of the effectiveness of a
CP delivered cardiovascular casemanagement programme. CPs
provided case management for CV
risk factors. The Heart Smart
programme was provided on-site for 3
years before the analyses.
BMI, BP,
cholesterol
profiles
To describe the effects of
implementation of a weight
management pharmaceutical care
service on a college campus.
Retrospective review of 289 patient
records.
Changes in body
weight and
weight related
conditions.
Review of the evidence for effective
weight reduction/management
interventions and development of a
clinical guideline.
-
programmes with
evaluation.
96/107 employees
were screened.
66/96 were eligible
and 36 enrolled at the
start of the
programme with 22
enrolling over the
next 3 years. There
was no difference in
weight
The net change in
weight per patient
was a decrease of
3.6kg ( 10% of
baseline weight).
Weight related
complications were
also reduced
Very small
numbers
Historical case
series
3
+/-
Results difficult to
generalise to
population
attending
community
pharmacies in
the UK. The
autors discuss
the limitations of
their pre test-post
test study.
Good quality
guideline with
adequate
description of
methodology.
Some evidence
may be outdated
Historical case
series
Good quality
guideline with
adequate
description of
methodology.
Some evidence
Guideline
3
+/-
Guideline
4
++
Australia
Clinical guideline for
obesity
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Review of the evidence for effective
weight reduction/management
interventions and development of a
clinical guideline.
Date: 11/02/2009
Page: 22 of 28
-
Managers and health
professionals in all
primary care settings
should ensure that
preventing and
managing obesity is a
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
4
National Public Health Service for Wales
and obesity in adults and
children. CG43. London:
NICE: 2006.
(Reference 18)
Weight management/community pharmacists
priority. Dedicated
resources should be
allocated for action.
Multicomponent
interventions are the
treatment of choice.
Weight management
programmes
should include
behaviour change
strategies to increase
people’s physical
activity levels or
decrease inactivity,
improve eating
behaviour and the
quality of the
person’s diet and
reduce energy intake.
Commercial weight
loss programmes
should only be
offered if they follow
best practice.
When
drug treatment is
prescribed,
arrangements should
be made for
appropriate health
professionals
to offer information,
support and
counselling on
additional diet,
physical activity and
behavioural
strategies.
England & Wales
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 23 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
may be outdated
++
National Public Health Service for Wales
Weight management/community pharmacists
Information about
patient support
programmes should
also be provided.
-up.
Pittler MH, Ernst E.
Complementary therapies
for reducing body weight: a
systematic review. Int J
Obes 2005; 29: 1030.
(Reference 19)
Literature on
complementary
therapies for weight
reduction.
Systematic review of RCTs and
additional literature on the
effectiveness of complementary
therapies in weight reduction.
-
Global
Rieck A, Clifford R, Everett
A. Community pharmacy
weight management
project. Stages one and
two (2005-2002). Perth:
University of Western
Australia; 2005.
(Reference15)
Community
pharmacies engaged
in weight management
programmes
Australia
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Stage one - literature review, policy
review and mapping process” to
identify;
a potential role for CPs in weight
management and the impact such a
service would have on CP and value
of the
professional service offered.
Stage two - to combine the findings of
the literature review with the
NHMRC clinical practice guidelines
and other government policies for the
management of
overweight and obesity, and develop
a CP weight management model.
Date: 11/02/2009
Page: 24 of 28
-
Six systematic
reviews and 25
additional RCTs met
the inclusion criteria.
The evidence related
to acupuncture,
acupressure, dietary
supplements,
homeopathy and
hypnotherapy. There
was only evidence for
hypnotherapy and
ephedrine containing
dietary supplements.
The findings of the l
literature review
suggest that a CP
weight management
programme can be
successful for CPs
and the healthcare
system in
treating clients who
are overweight and
obese if the following
key success factors
are taken into
account: client factors
 remuneration
 training and
accreditation
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
Systematic
reviews
1-
++
Comprehensive
review with
information
applicable to UK.
Literature review
3
++
National Public Health Service for Wales
Royal Pharmaceutical
Society of Great Britain.
Public health; a practical
guide for community
pharmacists. London:
RPSGB; 2004
(Reference 23)
The School of Pharmacy,
University of London.
Greater expectations.
Pharmacy based health
care – the future for
Europe? London: University
of London; 2007
(Reference 25)
Guide for CPs on the
broader concepts of
public health
Weight management/community pharmacists
Review of the evidence and expert
opinion
UK
6000 people surveyed
in 6 European
countries– France,
Germany, Greece,
Poland, Sweden and
the UK.
Questionnaire survey designed to
review the development of
community pharmacy in 5 European
countries and compare it with the UK.
Europe
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 25 of 28
-
 pharmacists role
and professional
barriers
The proposed
evidence based
model for CPs is
described in detail
with methods for
implementation
designed to try and
overcome the known
barriers. Stages 3
and 4 of the project
will describe the
results of
implementation of the
CP model
The authors conclude
that further research
is required on the
effectiveness of CP
led weight
management
programmes
Across Europe 64 per
cent of people agreed
that CPs should be
developed as
alternatives to
doctors' clinics.
Support for extending
pharmacy based
health care is
strongest in the UK
and Poland.
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
Review/expert
opinion
3/4
+
Provides useful
information on
successful CP
initiatives that
could be of
relevance to the
development of a
CP led weight
management
programmes
Qualitative
Level 3
++
National Public Health Service for Wales
Weight management/community pharmacists
Appendix 4 Components of weight management
programmes
Community pharmacists provide the components of a weight management
programme (except surgery) in a variety of ways. 15 These are examined in
detail below:Dietary advice
All community pharmacy programmes include dietary advice; however the
level of specificity for each individual client varies. For some people, an
increase in knowledge will be sufficient to produce a behaviour change, if they
are well-motivated. However, some people may require more specific
strategies. A focus group of obese clients reported that they had been given
diet sheets and low-calorie recipes but still failed to lose weight. Commercial
slimming programmes such as Weight Watchers provide clients with an
individualised plan. A CP weight management programme must include
dietary advice to create a negative energy balance. For some clients, it may
be appropriate for pharmacists to educate the client with dietary advice, which
creates this negative energy balance and promotes eating habits that can be
maintained long term. For the type of client requiring more specific strategies,
a plan individualised to the needs of the client is probably required, and if the
pharmacist does this, this will take more time. Other options are referral to a
dietician or use of an expert online or via telephone.
Physical activity
The evidence indicated that it is more difficult to create a negative energy
balance for short term weight loss with physical activity than it is with dietary
measures. Therefore most CP and non-community pharmacy programmes
provide advice with respect to an increase in physical activity, but it does not
appear to be a major focus of the programme. A CP programme should at
least promote an increase in lifestyle based activity because even if it doesn’t
assist in weight loss, it may result in improvements in other aspects of
metabolic health.
Behaviour modification
Most CP programmes encourage some form of behaviour modification to try
and achieve a more permanent weight loss solution. Some programmes
provide written material or instructional audiovisual material. The wellmotivated client may not require as much help with behaviour modification,
but a client with a history of failed diet attempts may benefit more from
behaviour modification strategies. A greater intensity of intervention and
individualised feedback, in comparison to giving clients general information to
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 26 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
National Public Health Service for Wales
Weight management/community pharmacists
read, also improves compliance with a programme which may achieve better
weight loss. Clients requiring more intense and individualised behaviour
modification will require more time investment by the pharmacist. Referral or
use of an expert via a telephone or online service may also be appropriate.
Support
Support of the client is provided in most CP accessible programmes and is
provided in a variety of ways. Some community pharmacy accessible
programmes require the clients to weigh themselves and record the results
with the option to ring an expert if desired. This appears to require more client
self-motivation. Some programmes have forums on the internet for
discussions with other people undertaking the same weight loss journey.
Other examples of support programmes provided by CP include information
seminars/workshops. Strong social support from a partner, peer, friend or
clinician can aid weight loss. One-to-one discussion on progress towards the
weight loss goal appears to be beneficial, whether by telephone or face toface. Individualised support will require a regular time investment by the
pharmacist. A telephone or on-line consultant could also be used.
Weight loss product
Community pharmacy accessible programmes may also include the client
taking a weight loss product. Compared with most non-community pharmacy
weight loss programmes, pharmacists are in the unique situation of being able
to suggest a suitable evidence-based weight-loss product or facilitate referral
to the GP, if this is deemed necessary and appropriate. A pharmacist can
then monitor the use of the product for safety and efficacy including
medication compliance.
Programme support materials
Information was provided via a variety of methods across all programmes
reviewed. This included brochures, fact sheets, newsletters, booklets,
audiovisual aids, audio tapes, and websites. In the case of some of the
products that can be bought from the pharmacy, the internet is the only
source of information for the weight management programme unless the
products are used under the direction of a health professional who is also
providing support. Being able to show the client their achievements with
respect to improving measurements may be more effective if it is more visual.
Decreased internet usage by lower socioeconomic groups and the over 55age group needs to be considered if provision of information on the internet is
considered for a pharmacy programme. Visual aids for demonstrating
achievements in weight loss to the client appear to be useful.
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 27 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team
National Public Health Service for Wales
Weight management/community pharmacists
Provision of other health-related services
Where a programme is operated from a CP, there is the opportunity for the
pharmacist to integrate other related services. These include reviewing the
client’s other medications for any which may be causing weight gain,
completing a compliance check if the client is taking a weight loss product as
part of the programme, and performing measures on blood glucose levels,
cholesterol and blood pressure, especially where weight loss and dietary
change may result in an improvement in these conditions. The latter may
then necessitate referral to the doctor for a review of other drug therapy.
Pharmacists should understand when to refer a client to the doctor if they
meet certain exclusion criteria for a weight loss programme
Promotion of the programme to the client
Media exposure is widely used for different areas of health promotion. For
greater uptake of the intervention by consumers, media promotion of a
pharmacy programme would appear beneficial so that in a prospective client’s
mind it is one of the available options. This would need to be considered in
the context of relevant pharmacy legislation.
Programme intervention initiator
The CP has the unique opportunity to raise the issue of weight management
with a client who may be in the pre-contemplation or contemplation stages of
behavioural change. This may be part of counselling associated with
dispensing of prescription medication used to treat conditions potentially
caused by the client being overweight. A CP programme may consider having
different resources for clients at different stages of decision making for a
behavioural change. This approach has been used successfully in some GP
based studies. Some of the pre-contemplation or contemplation stage clients
may move to a decision or action stage of readiness to change.
.
Length of programme
Success of a weight management programme should be assessed by the
ability to achieve and maintain a clinically helpful and significant weight loss
and recognise the beneficial effects of this weight loss on other conditions
such as type 2 diabetes, hypertension and dyslipidaemia. This highlights the
importance of the maintenance phase in any weight management
programme. Most of the programmes reviewed have a weight loss and
maintenance phase. Relapses in obesity are common. Constant vigilance in
monitoring energy input and expenditure predicts long-term success, and this
can be aided by regular monitoring and encouragement from the “clinician”
over the long term, and ideally for life.
Author: Dr Mary Webb, Public Health
Practitioner
Version: 1.a
Date: 11/02/2009
Page: 28 of 28
Status: Final
Intended Audience: Pharmaceutical
Public Health Team