The personal touch

Population Health

The personal touch

In Population Health

With the UK seemingly existing on a diet of ultra-processed food and the pharmaceutical industry relying on treating but never curing chronic disease, there’s an opportunity for pharmacists to make a difference to people’s health through targeted monitoring and nutritional and lifestyle advice. The results can be spectacular

A couple of years ago I came across an article in the pharmacy press entitled: ‘The cholesterol and calorie hypotheses are both dead – it is time to focus on the real culprit: insulin resistance’.

What I find so remarkable is that the article seemingly sank without trace. Why? Perhaps because there is simply too much cognitive dissonance for us to challenge the received wisdom that “a calorie is a calorie” and “fat makes us fat and clogs our arteries”. 

How awful would it be if we were to discover that all those prescriptions for statins did as much harm as good?

Meanwhile, outside the world of pharmacy, a debate is raging in the medical profession about the purpose of medicine and the value of medical interventions in an era of non-communicable disease. Just like in pharmacy, medical training lacks any significant focus on nutrition, lifestyle, exercise, stress and sleep, so the default position is to reach for the prescription pad. Prevention is ignored; we focus on some form of medical “cure”. It is akin to locking the door after the horse has bolted.

In short, we need to have the same debate in pharmacy if we are not to miss the boat. 

Trapped?

Are we trapped in a paradigm dominated by ‘big food’ on the one hand and ‘big pharma’ on the other? Is there an informal but unholy alliance between the food industry, which makes most of its profits from processed food, and the pharmaceutical industry, whose business model relies upon treating, but never curing, chronic disease? 

Think about it. Most diseases are treated symptomatically. Stop taking your metformin, for example, and the underlying condition (type 2 diabetes) simply returns.

The UK is the largest consumer of ultra-processed food in Europe, with a diet full of sugar, carbs and unhealthy fats. This raises insulin and results in metabolic syndrome (a cluster of diseases such as obesity, prediabetes, type 2 diabetes, cardiovascular disease, dementia and poly-cystic ovary syndrome, to name a just few). As a result, overall life longevity is decreasing for the first time since the inception of the NHS. 

Interestingly, the health secretary, Matt Hancock, seems to believe that prevention is better than cure. As he has noted: “Each year, we are spending £97bn of public money on treating disease and only £8bn preventing it across the UK – that’s an imbalance in urgent need of correction.” Let’s hope he means it.

The service is personalised and holistic

Healthy living

In my pharmacy we run an individualised coaching service aimed at preventing or reversing so-called metabolic syndrome.

During 2018, building on our healthy living pharmacy status and our interest in promoting healthy longevity, we introduced the ProLongevity service. This is a private scheme aimed directly at preventing or reversing the effects of metabolic syndrome. The service is personalised and holistic. 

We consider diet, nutritional status, exercise, sleep, stress, bio-markers such as lipid profile, liver function, HbA1c and cardiovascular health. Emphasis is placed primarily on what matters most to clients and patients.

One client, for example, was struggling to lose her ‘baby weight’; another with polycystic ovary syndrome wanted to get pregnant. Most of our clients want to prevent or reverse pre-diabetes or type 2 diabetes. 

Lasting eight weeks, the service involves continuous blood glucose monitoring coupled with a series of incremental lifestyle interventions. The client is asked to complete a detailed food diary and lifestyle questionnaire. With the client’s permission we gather the biometric data such as lipid profile, liver function tests and HbA1c from their GP. 

The service can be provided face-to-face, virtually, or any combination of the two. At the end of the first two weeks we are able to make an assessment of the client’s eating habits (which importantly includes when as well as what the client eats). At this point a detailed intervention is made and unhealthy foods (those which cause sugar spikes) are swapped for healthy alternatives. 

Clients are encouraged to favour a plant-based diet, with around 1g/kg/day of lean protein, reduced or minimal carbs (20g-50g/day) and an emphasis on omega-3 fats. No calorie counting is involved and clients are not hungry. Exercise is encouraged. Our results are consistently encouraging and occasionally spectacular. 

The following case studies are broadly representative:

Stuart, a GP aged 63

“Twelve months ago I was chatting to Graham about my physical demise… metabolic syndrome; obese; clothes not fitting (even 40 inch waist trousers); hypertensive (poorly controlled and worried about the risk of a stroke). I also had sleep apnoea and gout with frequent painful joints requiring strong painkillers and anti-inflammatories, which gave me severe dyspeptic symptoms. Worst of all, I had prediabetes. 

Graham told me about his eight-week programme. I stopped putting sugar in my tea and coffee, stopped drinking cartons of juice, stopped biscuits, cake, rice, chips and sweeteners and, along with the low carb diet, started to exercise more. Within two months I felt so much better and now, nearly three months on, I have dropped my waist size to 36 inches and my sleep apnoea seems to have gone. 

My HbA1c is normal, my gout has gone, my psoriasis has improved, and my concentration is so much better. But the best news is that even though I have stopped monitoring my blood sugar I am maintaining my progress and I can still have the odd piece of cheesecake. I feel 10 years younger.”

Chris (34), a public affairs consultant

“In my early 20s I was in the Royal Engineers, running 30 miles a week. After starting to work long hours in the private sector, however, the running gave way to the box set, healthy food was replaced with quick food – or no food at all.

I had become complacent and comfortable with being fat. What little willpower I had led me to follow the latest fad diet, which lasted a couple of weeks before returning to the same destructive cycle, leaving me demoralised and resigned to being ‘a bit fat’ – in reality, morbidly obese.

This service and the FreeStyle  Libra glucose monitor changed all that. It was explained to me that I was not taking in too many calories – far from it. In fact I was suffering from malnutrition. I had hardly any nutrients in my diet – just empty calories. 

Graham guided me through the difficult first few weeks, helping me to pick the right food – but also food that I would enjoy. We worked together, using the apps to ‘gamify’ the process – a great way to stay motivated to lose weight and, more importantly, improve your overall health. The fact that his service was available via Skype, WhatsApp and Facetime made everything so much more convenient

Over the last three months my blood pressure has returned to healthy levels. I’ve lost nearly two stones but the biggest surprise of all is that I’ve enjoyed the process. For all the science and technology, it’s the human touch that made it work for me.”

Conclusion

In my view it is inevitable that GPs will continue to be over-whelmed with the workload of treating illness. However, the nationwide network of healthy living pharmacies is an obvious solution to the illness burden. We need to prove what we are capable of and argue for investment in the network.

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