Pharmacist Intervention Enhances Adherence to Orlistat Therapy

Impact of a pharmacist-run weight loss medication management service

BACKGROUND

Weight loss medications have been shown to be effective for weight loss and reducing disease state risk in patients who are overweight or obese. However, it is unknown what impact pharmacists have on weight loss when providing medication management services.

OBJECTIVE

To evaluate weight loss outcomes and clinic utilization of a pharmacist-run weight loss pharmacotherapy service at the VA Tennessee Valley Healthcare System (TVHS) in Nashville, TN.

PRACTICE DESCRIPTION

Patients enrolled in the MOVE! weight loss program were referred to a clinical pharmacy specialist (CPS) who was able to assess comorbidities, prescribe weight loss medication, and provide ongoing follow-up via telehealth visits.

PRACTICE INNOVATION

This is the first description of a pharmacist-run weight loss pharmacotherapy clinic. This model expanded the role of pharmacists at TVHS, where CPS involvement was previously limited to chart reviews when medication recommendations were requested.

EVALUATION

This prospective quality improvement project evaluated patients seen by the CPS in the first 6 months of clinic implementation. Primary outcomes included change in weight and proportion of patients with at least 5% weight loss at the end of the study period. Results were compared with patients seen by preventative medicine providers (PMPs) in the same time frame.

RESULTS

A total of 79 patients were seen in the CPS clinic, and 40 met inclusion criteria. The clinic utilization rate was 100%. Mean weight change was -3.6 ± 5.7 kg (P < 0.001), and 25% of patients followed up by the CPS lost at least 5% body weight. In the PMP clinic, 29 patients demonstrated a mean weight change of -1.6 ± 6.0 kg (P = 0.15 compared with baseline), and 17.2% lost at least 5% body weight.

CONCLUSION

This pharmacist-led weight loss clinic demonstrated statistically significant reductions in weight and was able to expand access to care for patients seeking weight loss services.

Exploring the Role of Community Pharmacists in Obesity and Weight Management in Qatar: A Mixed-Methods Study

Introduction

Obesity is a major public health burden in Qatar. Pharmacists can play an important role in providing weight management services (WMSs). This study aimed to explore their attitudes, practice, perceived competence, and role in WMSs in Qatar.

Methods

A mixed-method explanatory sequential design was applied in the study. A validated online questionnaire was administered followed by qualitative individual and focus group interviews.

Results

Two-hundred seventy community pharmacists completed the survey (response rate 45%). More than half of them indicated that they often or always explain to patients the risks associated with overweight and obesity (56.2%), recommend weight loss medications, herbs or dietary supplements (52.4%), and counsel about their proper use and/or side effects (56.9%). Conversely, the majority of the pharmacists rarely or never measure patients’ waist circumference (83.8%) or calculate their body mass index (72.1%). Over 80% had very positive attitudes towards their role in weight management. Around three-quarters of the participants agreed or strongly agreed that difficulty in following-up with patients (80.7%), lack of private consultation area (75.7%), and lack of pharmacist’s time (75.2%) are barriers for implementing WMSs. More than 60% stated that they are fully competent in 7 out of 24 WMSs listed. Some themes generated include pharmacist’s role and impact in weight management, need for training about weight management, and impact of social media on patients’ perceptions.

Conclusion

Qatar community pharmacists reported positive attitudes towards the provision of WMSs. However, they identified several barriers against provision of WMSs. Several strategies are proposed to overcome barriers and to improve the provision of WMSs in community pharmacies in Qatar.

Role of community pharmacists in weight management: results of a national study in Lebanon

BACKGROUND

Ideally situated within the community, pharmacists can be involved in a broad range of health promotion campaigns including prevention of obesity. Limited evidence is available regarding their involvement in weight management in Lebanon, a country with escalating prevalence rate of obesity.

OBJECTIVE

To examine the role of community pharmacists in weight management in Lebanon, specifically studying their beliefs, current practices, services, and knowledge.

METHODS

Using a stratified random sampling approach, a cross sectional national survey of community pharmacists was conducted (n = 341, response rate 89%). At the pharmacy, and through a face-to-face interview, pharmacists completed a multi-component questionnaire that addressed, in addition to socio-demographic and work characteristics, their beliefs, practices, knowledge in relation to weight management. Frequencies and proportions were used to describe the data. Simple and multiple linear regression analyses were used to examine the determinants of knowledge in the study population.

RESULTS

Over 80% of study participants agreed that they have an important role to play in weight management. However, 50% of pharmacists did not agree that weight loss products are well regulated and 81.1% thought that companies marketing weight loss products are making false promises. The majority of pharmacists always/often sold weight loss products (84.7%) and counseled their patients for diet (86.3%) and physical activity (91.7%). Despite taking weight and height measurements, 50% of pharmacists rarely/never calculated BMI. Among the pharmacists who reported side effects of weight loss products (46.5%), the majority (91.3%) did so to the pharmaceutical company. The knowledge of pharmacists was better for the use of weight loss products as opposed to their side effects and interactions. Significant predictors of knowledge were holding a Masters/ PhD degree in Pharmacy, graduating from a university inside Lebanon, obtaining weight management training within the academic degree, and receiving inquiries about weight management in the pharmacy more than once daily.

CONCLUSIONS

The results of the study provided important insights on the beliefs, practices and knowledge of community pharmacists in weight management in Lebanon. These findings could be used to inform the development of future evidence-based community pharmacists led weight management service provision nationally and internationally.

"Each one has their own role": Exploratory study on consumers' perceptions about nutritionists services provided in community pharmacies

Obesity and overweight have grown to epidemic proportions in the past decades. To tackle this rising threat to health systems, lifestyle changes and nutritional education have been promoted through specialized programs and nutritional primary health care services. Community pharmacies adjustment to a new paradigm of pharmacy services means that they are not just a place for buying and selling medicines, but increasingly a space for diverse health care services. One such service addresses the weight problems of community pharmacy users through the provision of nutrition consultation services. In Portugal, these consultations are provided by nutritionists, many times under formal agreements with nutritional supplements commercial brands.

METHODS

The aim of this exploratory study was to characterize the experience of people attending nutrition consultations at two different pharmacies and to understand their perception of the role community pharmacists may have in weight management. To conduct this study, interviews were performed following an interview guide comprised of sociodemographic characterization questions and open-answer questions.

RESULTS

Ten people participated in the study, seven females and three males. The average self-reported BMI of the sample was 29.4Kg/m2. The results showed that there is a general satisfaction with nutrition consultations, with all respondents agreeing that community pharmacies are a right place to have these consultations. Accessibility and low cost were found to be the biggest advantages in having nutrition consultations at a pharmacy. On the other hand, these participants felt that the biggest disadvantage was the price of nutritional supplements. Lack of motivation was also seen as a major impediment to continue with the nutrition consultations. When participants were asked about what role community pharmacists may have in weight management, 50% of participants disagreed with the idea of pharmacists providing the service on their own.

CONCLUSION

the results of this study indicate that the degree of satisfaction of those attending the nutrition consultations is high, especially because of pharmacies' accessibility and proximity, hinting at the idea of efficiency as an important factor driving the demand for new health care services. Pharmacists were viewed as having a gatekeeper role, but the nutrition service provision should be exclusively provided by nutritionists, in an example of successful multidisciplinary practice within the community pharmacy setting. Future studies should focus on the effect these consultations have on the loss or maintenance of weight, including the comparison with service provision in the traditional settings.

Acceptability of alginate enriched bread and its effect on fat digestion in humans

Lifestyle interventions and physical activity remain the cornerstone of obesity management, as pharmacological therapies (orlistat) are associated with gastrointestinal (GI) side effects. Combining orlistat with fibers can reduce side effects, improving compliance. Therefore, a fiber that inhibits lipase without side effects could help treat obesity.

The aims of the present work were to assess whether alginate enriched bread could inhibit fat digestion, and assess the acceptability of alginate bread and its effect on GI wellbeing.

A double-blind, randomised, controlled cross-over pilot study (NCT03350958) assessed the impact of an alginate bread meal on; lipid content in ileal effluent and circulating triacylglycerol levels. This was compared against the same meal with non-enriched (control) bread.

GI wellbeing and acceptability of alginate bread was compared to control bread through daily wellbeing questionnaires and food diaries (NCT03477981). Control bread followed by alginate bread were consumed for two weeks respectively.

Consumption of alginate bread reduced circulating triacylglycerol compared to control (2% reduction in AUC) and significantly increased lipid content in ileal effluent (3.8 g ± 1.6 after 210 min).

There were no significant changes to GI wellbeing when comparing alginate bread to control bread. A significant increase in the feeling of fullness occurred with alginate bread compared to baseline and the first week of control bread consumption.

This study showed that sustained consumption of alginate enriched bread does not alter GI wellbeing and can decrease lipolysis, increasing lipid leaving the small intestine.

Further studies are required to demonstrate that reduced fat digestion through the action of alginate can reduce fat mass or body weight.

•

Alginate can be incorporated into a highly acceptable loaf at 4%.

•

Sustained (two weeks) consumption of alginate bread did not affect GI wellbeing.

•

Consumption of alginate bread decreases circulating triglyceride after the meal.

•

Consumption of alginate bread increases lipid leaving the ileum after the meal.

Strategies for Expanding Access and Improving the Quality of Pharmaceutical Services

Pharmaceutical services are among the most accessible healthcare assistance systems worldwide, being provided generally in enterprises like Drugstores and Compounding Pharmacies. Pharmacists are highly accessible healthcare professionals considering also the availability, geographic distribution and location of pharmaceutical enterprises. However, there are several challenges for providing these services for patients with limitations such as low education, difficulties on reaching the Pharmacist, and the need for individualized monitoring (due to the complexity of therapy). Reports of low quality services are growing worldwide, and in order to expand access and improve the quality of pharmaceutical services, Pharmacists must move from being medication dispensers with focus in administrative management to a clinically-oriented practice with a humanistic view. The aim of this chapter is to make an approach on the implementation of effective strategies and ways to improve the quality of Pharmacists' work as specialized healthcare providers.

Obesity: Implementation of a Weight Management Pharmaceutical Care Service

Background:

Obesity, a national epidemic, is one of the leading causes of preventable morbidity and mortality in the US. Pharmacists can play an integral role in weight management. Offering weight management services provides an opportunity to increase public awareness of pharmaceutical care and attract patients to pharmacy programs.

Objective:

To describe the implementation and evaluate outcomes of a weight management pharmaceutical care service in a stand alone pharmaceutical care center on a college campus.

Methods:

A retrospective review of data was conducted on 289 patient charts to evaluate the change in weight, body mass index (BMI), percent body fat, and weight-related health conditions in patients who participated in the Healthy Habits program.

Results:

The net change (change in values observed from first to last appointment) in weight was a loss of 1021.8 kg. The maximum weight change (change seen from the first appointment to the lowest value obtained during the program) was a loss of 1530.5 kg. These values correspond to a net mean weight loss of 3.6 kg per patient (10% of baseline weight) and a maximum mean weight loss per patient of 5.5 kg (15% of baseline weight). Eighty-three patients were able to decrease their BMI category and 76 patients had a decrease in risk status from baseline.

Conclusions:

The Auburn University Pharmaceutical Care Center's Healthy Habits program has been successful in helping patients decrease total body weight, BMI, and risk of weight-related complications. In addition, the program has increased the opportunity to identify other pharmaceutical care needs of patients and help establish the role of pharmacists in the management of obesity.

Community pharmacy interventions for public health priorities: a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

Background

The Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities.

Objectives

To systematically review the effectiveness of community pharmacy interventions to manage alcohol misuse, smoking cessation and weight loss; to explore if and how age, sex, ethnicity and socioeconomic status moderate effectiveness; and to describe how the interventions have been organised, implemented and delivered.

Data sources

Ten electronic databases were searched: Applied Social Sciences Index and Abstracts; Cumulative Index to Nursing and Allied Health Literature; EMBASE; International Bibliography of the Social Sciences; MEDLINE; NHS Economic Evaluation Database; PsycINFO; Social Science Citation Index; Scopus; and the Sociological Abstracts from inception to May 2014. There was no restriction on language or country. Supplementary searches included website, grey literature, study registers, bibliographies and contacting experts.

Review methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Any type of intervention of any duration based in any country and in people of any age was included. The review included interventions set in a community pharmacy and delivered by the pharmacist or the wider pharmacy team. Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies were included. Data extraction and quality assessment were conducted independently for each study by two reviewers. Meta-analysis and narrative synthesis were also conducted.

Results

The searches identified over 14,000 records, of which 24 studies were included. There were two alcohol, 12 smoking cessation, five weight loss and five multicomponent interventions that included pharmacotherapy and lifestyle changes in participants with diabetes mellitus, dyslipidaemia or hypertension. Nine of the studies were UK based; seven of the studies were rated ‘strong’ for quality. All studies were of adults. Pharmacy-based smoking cessation interventions including behavioural support and/or nicotine replacement therapy are effective and cost-effective in helping adults to stop smoking, particularly when compared with usual care. The pooled odds ratio of the intervention effects for smoking cessation was 1.85 (95% confidence interval 1.25 to 2.75). It is currently unknown which specific types of smoking cessation interventions are the most effective. There was insufficient evidence for the effectiveness of community pharmacy-based brief alcohol interventions. Evidence suggests that pharmacy-based weight-loss interventions are as effective as similar interventions in other primary care settings, but not as effective or cost-effective as commercially provided weight management services based in community settings. None of the five multicomponent studies demonstrated an improvement compared with control for anthropometric outcomes in participants with comorbidities, but they did show improvement in measures associated with the comorbidities. Very few studies explored if and how sociodemographic or socioeconomic variables moderated the effect of interventions. In two studies based in areas of high deprivation, where participants chose the intervention, the sociodemographic characteristics of participants differed between intervention settings. There were also differences in recruitment, attendance and retention of participants by type of setting. The evidence suggests that a distinct group of people might access pharmacies compared with other settings for alcohol management, smoking cessation and weight loss. There is insufficient evidence to examine the relationship between behaviour change strategies and effectiveness; or evidence of consistent implementation factors or training components that underpin effective interventions.

Limitations

The information reported in the publications of included studies did not allow us to assess in detail if and how age, sex, ethnicity and socioeconomic status moderate effectiveness, or to describe how the interventions had been organised, implemented and delivered.

Conclusions

Community pharmacy interventions are effective for smoking cessation. Evaluations of interventions to manage alcohol misuse and obesity, set within the community pharmacy, are needed. The effect of community pharmacy interventions on health inequalities is unclear. Future research in this area is warranted, and trials should include the assessment of age, sex, ethnicity, socioeconomic status and contextual factors, and present analysis of how these factors moderate effectiveness.

Study registration

This study is registered as PROSPERO CRD42013005943.

Funding

The National Institute for Health Research Public Health Research programme.

Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation and weight management, including meta-analysis for smoking cessation

OBJECTIVES

To systematically review the effectiveness of community pharmacy-delivered interventions for alcohol reduction, smoking cessation and weight management.

DESIGN

Systematic review and meta-analyses. 10 electronic databases were searched from inception to May 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

STUDY DESIGN

randomised and non-randomised controlled trials; controlled before/after studies, interrupted times series.

INTERVENTION

any relevant intervention set in a community pharmacy, delivered by the pharmacy team. No restrictions on duration, country, age, or language.

RESULTS

19 studies were included: 2 alcohol reduction, 12 smoking cessation and 5 weight management. Study quality rating: 6 'strong', 4 'moderate' and 9 'weak'. 8 studies were conducted in the UK, 4 in the USA, 2 in Australia, 1 each in 5 other countries. Evidence from 2 alcohol-reduction interventions was limited. Behavioural support and/or nicotine replacement therapy are effective and cost-effective for smoking cessation: pooled OR was 2.56 (95% CI 1.45 to 4.53) for active intervention vs usual care. Pharmacy-based interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings compared with control. Pharmacy-based weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations. Very few studies explored if and how sociodemographic or socioeconomic variables moderated intervention effects. Insufficient information was available to examine relationships between effectiveness and behaviour change strategies, implementation factors, or organisation and delivery of interventions.

CONCLUSIONS

Community pharmacy-delivered interventions are effective for smoking cessation, and demonstrate that the pharmacy is a feasible option for weight management interventions. Given the potential reach, effectiveness and associated costs of these interventions, commissioners should consider using community pharmacies to help deliver public health services.

Pharmacist interventions for obesity: improving treatment adherence and patient outcomes

Obesity is currently a worldwide pandemic, with overweight (body mass index [BMI] ≥25 kg/m2) and obesity (BMI ≥30 kg/m2) estimated at 35% and 12% of the global adult population, respectively. According to data collected from the United States National Health and Nutrition Examination Survey, approximately 68.8% of US adults are overweight or obese. Additionally, a large burden of health care costs can be attributed directly to obesity as well as multiple, potentially preventable, comorbidities such as cancer, cardiovascular disease, and diabetes. As a result, national and international organizations, such as the US Centers for Disease Control and World Health Organization, have made halting the rise of the obesity epidemic a top priority. Pharmacists, commonly considered one of the most trustworthy and accessible health care professionals, are ideally situated to provide counseling for weight and lifestyle management. This review presents examples of pharmacist-led as well as collaborative practices that have been somewhat successful in educating and monitoring patient progress in attaining weight-loss goals. Common barriers and potential solutions to administration of lifestyle counseling and monitoring programs, such as limited pharmacist time and resources, lack of expertise and/or confidence in program administration, and patient perception and awareness, are also discussed.

What is the Role of the Pharmacist in Obesity Management?

Obesity rates have increased over the last two decades. Based on NHANES data, 68.8 % of US adults are classified as overweight or obese. Obesity increases the risk of diseases and can contribute to increased morbidity and mortality. This review examines studies published in which pharmacists have provided weight management services alone or in a team. The electronic databases OVID Medline, International Pharmaceutical Abstracts and EMBASE (1946-2014) were searched. Nine articles were identified in which pharmacists delivered a weight management service either alone or in a team, and eight studies collected outcomes. Six studies evaluated the participant's weight loss or satisfaction with the service, and two studies evaluated weight loss associated with a meal-replacement program. The outcomes from these studies are limited and while positive, have failed to provide significant evidence of the impact of pharmacists providing these services. More randomized, controlled trials are needed to document weight management services.

A comparison of the provision of the My Choice Weight Management Programme via general practitioner practices and community pharmacies in the United Kingdom

This study aimed to assess the effectiveness of a novel, community-based weight management programme delivered through general practitioner (GP) practices and community pharmacies in one city in the United Kingdom. This study used a non-randomized, retrospective, observational comparison of clinical data collected by participating GP practices and community pharmacies. Subjects were 451 overweight or obese men and women resident in areas of high socioeconomic deprivation (82% from black and minority ethnic groups, 86% women, mean age: 41.1 years, mean body mass index [BMI]: 34.5 kg m(-2)). Weight, waist circumference and BMI at baseline, after 12 weeks and after 9 months were measured. Costs of delivery were also analysed. Sixty-four per cent of participants lost weight after the first 12 weeks of the My Choice Weight Management Programme. There was considerable dropout. Mean percentage weight loss (last observation carried forward) was 1.9% at 12 weeks and 1.9% at final follow-up (9 months). There was no significant difference in weight loss between participants attending GP practices and those attending pharmacies at both 12 weeks and at final follow-up. Costs per participant were higher via community pharmacy which was attributable to better attendance at sessions among community pharmacy participants than among GP participants. The My Choice Weight Management Programme produced modest reductions in weight at 12 weeks and 9 months. Such programmes may not be sufficient to tackle the obesity epidemic.

The modulation of pancreatic lipase activity by alginates

Alginates are comprised of mannuronic (M) and guluronic acid (G) and have been shown to inhibit enzyme activity. Pancreatic lipase is important in dietary triacylglycerol breakdown; reducing pancreatic lipase activity would reduce triacylglycerol breakdown resulting in lower amounts being absorbed by the body. Lipase activity in the presence of biopolymers was assessed by enzymatic assay using natural and synthetic substrates. Alginate inhibited pancreatic lipase by a maximum of 72.2% (±4.1) with synthetic substrate (DGGR) and 58.0% (±9.7) with natural substrate. High-G alginates from Laminaria hyperborea seaweed inhibited pancreatic lipase to a significantly higher degree than High-M alginates from Lessonia nigrescens, showing that inhibition was related to alginate structure. High-G alginates are effective inhibitors of pancreatic lipase and are used in the food industry at low levels. They could be included at higher levels in foods without altering organoleptic qualities, potentially reduce the uptake of dietary triacylglycerol aiding in weight management.

Adherence and non-adherence to treatments: focus on pharmacy practice in Nepal

Nepal is one of the developing countries having many limitations in providing the quality health services to its population. In many countries, improvement in patients' adherence to the pharmacotherapy had been one of major outcome of quality pharmaceutical services. Till date, very less thing has been done in this area in Nepal; so it seems mandatory to improve the patient adherence to the treatment plans. Adherence to the medical therapy can be explained by the extent of the behavioral coincidence to the medication and non-medication regimen by a patient whereas compliance and concordance are two different models of patient adherence to the therapy. Compliance model suggests that patients have been brought responsible for being unable to follow 'doctor's order and concordance tempts to measure the degree of agreement between patient and his or her clinician about the nature of illness and the best possible therapy for the welfare of the patient. Non-adherence to the therapy may lead to different problems as consequences of non-adherence in four different level- individual, institutional, societal and national levels. Although some programs like, "Direct Observation Treatment, Short-course (DOTS) for tuberculosis, implementation of antiretroviral treatment schedules for HIV patients and pediatric vaccination models," are the examples of attention towards the cases of noncompliance in Nepal. It has long been faced its limitations in the forms of either untrained manpower or lack of good documentation of patients' adherence to therapy or high illiteracy rate or unaffordibility of patients to their treatment or lack of pharmaceutical care services.

Community Pharmacists role in obesity treatment in Kuwait: a cross-sectional study

BACKGROUND

Obesity is a growing health concern in Kuwait. Obesity has been identified as a key risk factor for many chronic diseases including hypertension, dyslipidemia and type 2 diabetes mellitus. It has been shown that community pharmacists' involvement is associated with successful weight management in developed countries. This study was conducted to investigate the role of community pharmacists in obesity counseling, and to identify the barriers to counseling in Kuwait.

METHODS

A descriptive cross-sectional study involved 220 community pharmacies that were selected via stratified and systematic random sampling. A pretested self-administered questionnaire collected information on frequency and comfort level with obesity counseling, and the perceived effectiveness of four aspects of obesity management (diet and exercise, prescribed antiobesity medications, diet foods, and nonprescription products and dietary supplements). Information on perceived confidence in achieving positive outcomes as a result of counseling and barriers to counseling was also collected. Descriptive and Spearman' r analysis were conducted using SPSS version 17. Responses with Likert scale rating 1(low score) to 5 (high score) and binary choices (yes/no) were presented as mean (SD) and (95% CI), respectively.

RESULTS

The response rate was 93.6%. The overall mean (SD) responses indicated that pharmacists counseled obese patients sometimes to most of the time, 3.67 (1.19) and were neutral to comfortable with counseling about aspects of obesity management, 3.77 (1.19). Respondents perceived obesity management aspects to be somewhat effective, 3.80 (1.05). Of the four aspects of obesity management, diet and exercise, and diet foods were the highest ranked in terms of frequency of counseling, comfort level and perceived effectiveness. Pharmacists were neutral to confident in achieving positive outcomes as a result of obesity counseling, 3.44 (1.09). Overall mean responses of counseling obese patients by pharmacists were positively correlated with their perceived comfort with counseling and perceived effectiveness of obesity management aspects. The most anticipated barriers to obesity counseling were lack of patient awareness about pharmacists' expertise in counseling 76.2% (95% CI: 69.7-81.7) and pharmacists' opinions that obese patients lack willpower and are non-adherent to weight reduction interventions 71.8% (95% CI: 65.1-77.8).

CONCLUSIONS

Strengths, weaknesses and barriers related to obesity counseling by pharmacists in Kuwait were identified, and suggestions were provided to strengthen that role.

Lightening the load? A systematic review of community pharmacy-based weight management interventions

The extent to which community pharmacies can increase capacity for weight management is unknown. Thus, the objective of the present paper was to evaluate the effectiveness and cost-effectiveness of community pharmacy weight management interventions. This paper used a design of systematic review and narrative synthesis. Electronic databases (1999-2009) were searched, including Medline, EMBASE, CINAHL and Pharm-line. Weight management studies in community pharmacies were eligible for the inclusion criteria. All languages and study designs were considered. Outcome measures included body weight or anthropometry (at baseline and at least one follow-up time point). Data were extracted through independent, duplicate data extraction and quality assessment. As a result, 10 studies were included, totalling 2,583 service users and 582 pharmacies from the USA, the UK, Switzerland, Spain and Denmark. One was a randomized controlled trial of a meal-replacement versus a reduced calorie diet. A non-randomized controlled before and after study compared community pharmacist treatment using Orlistat with usual care. Eight studies were uncontrolled. Five studies described behaviour change techniques. Long-term (12 months) mean weight loss measured in three studies ranged from 1.1 to 4.1 kg. Four uncontrolled studies reported statistically significant weight loss. No study reported economic evaluations. Currently, there is insufficient evidence for the effectiveness and cost-effectiveness of community pharmacy-based weight management initiatives to support investment in their provision.

Predictors of weight loss and maintenance in patients treated with antiobesity drugs

BACKGROUND

The prevalence of obesity and related diseases has increased enormously in the last few decades, becoming a very important medical and social issue. Because of the increasing number of people who need weight loss therapies and the high costs associated with these, the search for reliable predictors of success for weight loss and weight maintenance treatments has become a priority.

OBJECTIVE

A literature review was undertaken to identify possible predictors of outcome of weight loss and weight maintenance in patients treated with antiobesity drugs.

RESULTS

For the majority of variables, published data are not sufficient to define their role on final outcomes. Among all considered factors, only early response to treatment appeared to be a reliable positive predictor, and diabetes a negative predictor of weight loss and maintenance.

CONCLUSION

To date, no definitive results have been obtained. Due to the great benefits of reliable predictors of outcome associated to currently available antiobesity drugs and those under development, identifying these predictors has to be supported and encouraged.

Managing obesity in pharmacy: the Australian experience

OBJECTIVE

To explore pharmacists' opinions about the provision of weight management services in community pharmacy and their attitudes towards the establishment of an accredited training course in weight management in pharmacy.

SETTING

Interviews were conducted with practising pharmacists on site in various community pharmacies in metropolitan Sydney, Australia.

METHOD

In-depth, semi-structured interviews with twenty practising pharmacists were conducted. Of the twenty interviewed pharmacists, sixteen were involved in the provision of one or more pharmacy based weight management programs in their pharmacies. Interviews were audio-recorded, transcribed and analysed using the grounded theory approach.

MAIN OUTCOME MEASURE

The data were thematically analysed to identify facilitators and perceived barriers to the provision of high quality services, and pharmacists' willingness to undertake training and accreditation.

RESULTS

Participants clearly perceived a role for pharmacy in weight management. Key facilitators to provision of service were accessibility and the perception of pharmacists as trustworthy healthcare professionals. The pharmacists proposed collaboration with other healthcare professionals in order to provide a service incorporating diet, exercise and behavioural therapy. A program that was not-product-centred, and supported by ethical marketing was favoured. Appropriate training and accreditation were considered essential to assuring the quality of such services. Barriers to the provision of high quality services identified were: remuneration, pharmacy infrastructure, client demand and the current marketing of product-centred programs.

CONCLUSION

Australian pharmacists believe there is a role for pharmacy in weight management, provided training in accredited programs is made available. A holistic, evidence-based, multi-disciplinary service model has been identified as ideal.

Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns

BACKGROUND

The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000.

OBJECTIVES

To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes.

SEARCH STRATEGY

This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update.

SELECTION CRITERIA

Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies.

MAIN RESULTS

Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns.

AUTHORS' CONCLUSIONS

Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.

Who will lose weight on sibutramine and orlistat? Psychological correlates for treatment success

AIM

To study the associations between weight loss with sibutramine and orlistat with psychological aspects that may interact with patients' response to these drugs.

METHODS

A total of 478 obese patients with a mean body mass index of 42 +/- 12 kg/m(2) gave self-reported, retrospective data on different types of previous weight loss treatments (sibutramine and orlistat, and Weight Watchers used as a control condition) including the amount of weight lost with these treatments, eating behaviour (Dutch Eating Behaviour Questionnaire) and personality (NEO Personality Inventory - Revised).

RESULTS

Greater weight loss with sibutramine was associated with lower levels of restrained eating and higher levels of 'neuroticism', in particular 'anxiety' and 'depression'. Greater weight loss with orlistat was associated with aspects of the personality dimension 'conscientiousness' (e.g. 'order' and 'deliberation').

CONCLUSION

Sibutramine may exert its greatest effect in patients whose eating is a 'natural' response to hunger rather than regulated by cognitions and conscious controls. Patients with low levels of restraint could be more sensitive to the satiety-enhancing effect of sibutramine. They may be able to reduce their food intake without cognitive interference and/or start to control their eating most radically in response to enhanced satiety. Enhanced satiety may also help patients withstand a wish to eat triggered by psychological distress. Possible central nervous system effects on mood could also have reduced eating, which was related to distress. The administration regimen of orlistat is more demanding, requiring greater adherence. This can account for the finding that personality attributes such as conscientiousness are important for success.

Medication compliance and persistence: terminology and definitions

OBJECTIVE

The aim of the study is to provide guidance regarding the meaning and use of the terms "compliance" and "persistence" as they relate to the study of medication use.

METHODS

A literature review and debate on appropriate terminology and definitions were carried out.

RESULTS

Medication compliance and medication persistence are two different constructs. Medication compliance (synonym: adherence) refers to the degree or extent of conformity to the recommendations about day-to-day treatment by the provider with respect to the timing, dosage, and frequency. It may be defined as "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen." Medication persistence refers to the act of continuing the treatment for the prescribed duration. It may be defined as "the duration of time from initiation to discontinuation of therapy." No overarching term combines these two distinct constructs.

CONCLUSIONS

Providing specific definitions for compliance and persistence is important for sound quantitative expressions of patients' drug dosing histories and their explanatory power for clinical and economic events. Adoption of these definitions by health outcomes researchers will provide a consistent framework and lexicon for research.

Barriers to counseling patients with obesity: a study of Texas community pharmacists

OBJECTIVE

To assess barriers to the counseling of obese patients and identify pharmacists' characteristics associated with these barriers.

DESIGN

Cross-sectional mail survey.

SETTING

Texas.

PARTICIPANTS

139 community pharmacists.

INTERVENTION

Self-administered questionnaire.

MAIN OUTCOME MEASURES

Respondents' perceived barriers to pharmacists' counseling of obese patients.

RESULTS

The top three barriers to counseling included lack of time (76.8%), lack of patient demand or expectations (55.8%), and lack of reimbursement/compensation (49.3%). Pharmacists indicated that they rarely to sometimes counseled obese patients and were somewhat comfortable with counseling about obesity management. They perceived obesity management strategies to be somewhat effective in weight loss, but were neutral regarding their confidence in achieving positive outcomes with counseling. Pharmacists who were more experienced were more likely to indicate that obesity is controllable without medications. Those who considered obesity controllable without medications were significantly more likely to view the various obesity management strategies as less effective, compared with those who did not share this belief. Pharmacists who viewed lack of privacy as a barrier were significantly less confident in achieving positive outcomes as a result of counseling. Creating awareness among patients about pharmacists' ability to counsel was perceived as most important in overcoming barriers.

CONCLUSION

Pharmacists identified several barriers to counseling of obese patients. Pharmacists' demographics and beliefs about obesity were significantly associated with their perceived barriers.

An update on evidence of clinical pharmacy services' impact on health-related quality of life

OBJECTIVE

To describe and critique recent studies of clinical pharmacy services that have evaluated impact on health-related quality of life (HRQL) and to determine whether studies that lacked a control group were more likely to report a statistically significant impact on HRQL.

DATA SOURCES

MEDLINE, EMBASE and International Pharmaceutical Abstracts were searched (March 1999-December 2004) using terms for HRQL and clinical pharmacy services.

STUDY SELECTION AND DATA EXTRACTION

All original research articles in English identified from the data sources were examined. Abstracts were screened by 2 reviewers, and studies were included if a clinical pharmacy service was evaluated and pre-/post - HRQL outcomes were reported.

DATA SYNTHESIS

Of 1152 citations identified by the literature search, 36 articles met the inclusion criteria. Twenty-two studies had a condition-specific focus. Fifteen studies incorporated a generic HRQL measure (primarily the short-form-36 items), 13 studies used a condition-specific measure, and 8 studies included both. Significant impact on one or more domains of HRQL was predominantly demonstrated in interventions relating to asthma, hypertension, and chronic heart failure. Statistically significant change in HRQL was reported in 8 of 21 studies that used a randomized controlled design (38%), in 2 of 5 studies with a nonrandomized design with control group (40%), and in 6 of 8 studies without a control group (75%; chi2 2.00; p = 0.16).

CONCLUSIONS

Since 1999, the number of published studies of clinical pharmacy services that evaluated HRQL as an endpoint has more than tripled. Study designs have improved in terms of longer length of follow-up, and a wider breadth of clinical services has been evaluated. Certain pharmacy services, such as asthma management, appear to offer the most convincing evidence for the value of clinical pharmacy services in terms of measurable short-term HRQL benefit.

Combating the obesity epidemic: community pharmacists' counseling on obesity management

BACKGROUND

Obesity is reaching an epidemic proportion in the US. Nearly two-thirds (64.7%) of US adults are overweight or obese. Given the myriad of issues related to the management of obesity, community pharmacists can facilitate weight loss among their patients.

OBJECTIVE

To identify factors that influence the frequency of counseling obese patients by community pharmacists.

METHODS

A mail survey was sent to a random sample of 400 Texas community pharmacists. The questionnaire collected information on frequency of counseling obese patients, perceived comfort level with counseling obese patients, perceived effectiveness of various obesity treatments, and perceived confidence in achieving positive outcomes as a result of counseling. Demographic information was also collected. Descriptive statistics, correlational analyses, and t-tests were used to examine the data.

RESULTS

A usable response rate of 35.2% was obtained (139 completed surveys out of 395 assumed delivered). Overall, pharmacists counseled patients rarely to sometimes about various aspects of obesity management. Correlational analyses revealed that pharmacists' frequency of counseling about obesity management was significantly and positively associated with their comfort level with counseling obese patients (r = 0.47; p < 0.001). Higher levels of confidence in achieving positive outcomes as a result of counseling (r = 0.39; p < 0.001) and higher levels of perceived effectiveness of obesity management options (r = 0.18; p = 0.037) were also significantly associated with higher levels of counseling about obesity management.

CONCLUSIONS

Obesity counseling by pharmacists was positively correlated with their perceived comfort with counseling obese patients, confidence in achieving positive outcomes, and effectiveness of obesity management options.