Community pharmacy's contribution to improving the public's health: the case of weight management

Abstract

The potential contribution of community pharmacy in public health has long been recog-nised, and even more so with increasing attention being paid to prevention of ill-health. In the UK the 2005 community pharmacy contract for England and Wales enshrined public health for the first time as part of the everyday work of the pharmacy. 1 All pharmacies are required to provide prescription-linked brief advice on issues such as smoking cessation and to participate in up to six local health campaigns each year. We have recently completed a third structured review of the international peer-reviewed literature on community phar-macy's contribution to improving the public's health. Our first two reviews covered the periods 1990-2001 and 2001-2004, 2,3 and found good evidence of effectiveness of community pharmacy services relating to lipid management and smoking cessation and some evidence in other areas. However, the number of robust evaluations was small and raised issues about the strength of the evidence base for community pharmacy interventions. Here we explore these issues further by considering the evidence of effectiveness for community pharmacy-based services for weight management. The UK Department of Health has funded a trial weight-management service in the Cov-entry Primary Care Trust, 4 and several local primary care organisations have commissioned pharmacies to provide such a service. The Pharmacy Guild of Australia recently sent Weight Loss Information Programme starter kits to pharmacies. 5 The kit contains information on products, exercise, eating plans and consultations, as well as tips on promotions and staff training. Individual pharmacists will decide how they implement the programme. We selected weight management as an exemplar because it is one of increasing public health concern, and one where, in the UK, the pharmacy contract negotiators and a parliamentary group inquiry have recommended that the government should fund a national weight-management service in community pharmacies. The question is-does the evidence justify the promotion of community pharmacies as a national resource for weight management? In our first review of the literature we found one study from Denmark which reported the results of 'slimming courses' held at 19 community pharmacies for 269 obese clients. 6 Average weight loss (self-reported by clients measured on scales in the pharmacy) was 5.3 kg for females and 6.2 kg for males. At one-year follow-up, 20% of clients who completed the course had maintained a weight loss of 5 kg or more. In the second review we found one US trial, in which participants were randomised to a meal replacement (MR) or reduced calorie diet (RCD) plan. 7 There was follow-up for a 3-month period of active weight loss then a 10-week period of weight maintenance. The programme involved 3-weekly visits to the pharmacy (13 visits in total). Eighty-eight of 95 participants attended at least one follow-up visit and were included in the analysis. Mean weight reduction in the active weight-loss phase was 4.9 kg in the MR group and 4.3 kg in the RCD group. In the weight-management phase the mean reductions were 0.7 kg in the MR group and 0.9 kg in the RCD group. Improvements were observed in waist circumference , systolic and diastolic blood pressure, and triglyceride levels. There were no significant changes in high-density lipoprotein (HDL) or low-density lipoprotein (LDL) cholesterol. For the period 2004-2007, six studies were identified and reviewed whose focus was specifically on weight management; three involved interventions. In two of these, the service was provided for a total of 316 people and in the third, which was an extension of a national health promotion campaign, it was provided for 1370. A US weight-management pharmaceutical care service was provided in a single pharmaceutical care centre on a college campus and evaluated. 8 The intervention was an initial consultation with the pharmacist scheduled for 1.5 hours, with 15-min follow-ups fortnightly until target weight was reached, then three-monthly. Data for 226 patients over the 7 years of the programme were reviewed. A further 57 people had an initial consultation and then dropped out. Mean individual weight loss was 3.6 kg, and mean duration of participation 26 weeks. One in three