Health and weight (young people)

Treatments through GPs, dietitians, counselling and surgery

Young people and their parents were often unsure whether they should talk to their GP about the weight problem, either because they hoped that the problem would go away on its own, or because they didn’t believe that there was anything the doctor could do. When the topic of weight came up in discussion with the GP, parents were sometimes told not to worry and that their child would grow out of their excess weight.
Emily thought that her GP was unhelpful and just said whatever he thought would keep them happy. Steevie’s GP told her that she was overweight but also said that it was probably because she was ‘hitting puberty’. Her mother joked about it afterwards and said the GP didn’t understand that their family were all on the large side.

Steevie doesn't entirely share her mum'’s belief that her genes are responsible for her weight.

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Sex: Female
When I was just hitting puberty, that’s when he was like, “Oh you’re a bit on the big side, but  don’t worry about it ‘cos you know, you’re hitting puberty now, so it’ll probably come off in time.”
And then, I remember leaving and me and Mum joking about it, and she was like, “Oh don’t worry. They don’t understand, you know, it’s genetics, and our family is like that. So they can’t measure you with another girl your age,” and, you know, they couldn’t measure you in the same way, because, our family is very different, and whereas, and it’s true ‘cos my, well I don’t think it’s all true, I think obviously I was just eating too much.
Looking back, some people were amazed that their doctor, health visitor, or practice nurse had not spotted the problem earlier. Shannon said that when she was a small child her mother thought she was overweight but the clinic staff said it was just ‘puppy fat’. Then, when she was 5 years old, they suddenly said, “What have you done wrong? She’s too obese”.

Sue's GP said that her daughter didn't need to diet. She is concerned that doctors are only...

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Age at interview: 45
Sex: Female
Yep I have, I’ve spoken, actually I’ve done it via the back door actually last time she went to see the doctor, she actually got mastitis, which at 12 was very unusual so I was keeping quite a close eye on that.  I spoke to the doctor afterwards and the doctor just said “Well, you know, she’s still growing, you know, it could change,” I thought okay, fine fair enough, it was a female doctor. I spoke to the school nurse who I actually know very, very well  and I asked her what she thought, I asked her what she thought and she said “Well, you know, they’re still growing and you don’t want to be putting them on diets,” and I’m thinking that’s what we’re saying, we’re saying do nothing… you know, when do you do something? Do you wait until they are, you know, horribly obese, morbidly obese before you do something, because that’s what they’re suggesting? And they’re talking about kids and no exercise and this that and the other, and yet that’s a huge thing, but these kids don’t want to exercise, you know, when I was enormous, you know, I didn’t particularly want to go pounding the streets, I didn’t want to be seen out in a t-shirt and shorts, you know.
I think they’re only just waking up to it, and I don’t think they really realise how urgent it is. You know, that there’s a time barrier, that’s what I’m aware of there’s a time barrier here, I have a time, a window of time when, when my daughter’s old enough to be able to influence her own change and say okay yes I’m going to do this and really put some effort into it and the end of that window when, when they are set in their ways and very little will change probably for the rest of their life. And there’s that window in there at the moment and I think it’s pretty short these days because kids are growing up so fast. She’s talking to me about things at 12 years old that I didn’t think of until I was 16 [laughter] she’s, you know, she’s obsessed with boys, her entire year are obsessed with the boys, you listen to them it’s all about boys, I didn’t even think about boys until I was about 14 or 15 and I wasn’t unusual it wasn’t that I was the odd one out at school, that, that sort of cycle happens and that was about the age group we really, really started thinking about boys, certainly wasn’t, it was certainly about 13 plus, it definitely wasn’t 12 and she’s been, they’ve been like this for six months maybe a year, it’s been building for six months to a year. They’re growing up much faster, they’re becoming more body aware much faster so that the image problems are coming on much faster, we can’t wait until they’re in their 20s to deal with them, we have to find a way of dealing with them now  and how we do that, I don’t know, but things like portion sizes, one of the things I read recently was that in America portion sizes have increased by ten times, ten times, I think it’s something like four to five in the UK, ten times in the US.

Vicki thinks there needs to be more support for teenagers who are overweight.

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Sex: Female
Well I think there should be like, as I said like a group, or like local groups or something for overweight people. And like you don’t have to broadcast it like, “Oh, we’re fat people, like roll up roll up,” kind of thing. Like just have some sort of, some thing to make people aware of and they wouldn’t listen, if they want to hear it or not. It’s important.
Like , and make things more, like teenagers trying to diet don’t have much money, like stop making everything so expensive for diets. Like that’s just the one thing that really annoys me, is how, and nothing is aimed specifically at teenagers, because everything is like 16+ as well, and well not everything, but most things are 16+ and like, just like, so some people are being, they’re getting to be overweight and getting to 16 it’s too late, like, they won’t change back because being overweight has been with them since they were young, and it’s shaped the person they’ve become, so they might not want to lose weight, but they, they, they shouldn’t if they don’t want to like, but.
Just more help for like younger teenagers, because it’s all well and good like people my age, like 18, 19, can get the help because they can go to the meetings, like Weight Watchers and stuff, and they can use all of the gym equipment and like as you can, like the people who are 16 and plus can like can go to most of the meetings and like most, use most gyms and stuff, but I think people under 16, like kids who are getting bigger I really think they need help as well, because, but they, rather than make it something nasty and stuff like, “Oh you’re a kid, and you’re fat,” kind of thing, like be nice about it, like try and. I don’t know just, help younger children as well like, ‘cos they’re, if you, if you look like you’re gonna get big when you’re younger you’re gonna get big for your teens as well, like, that’s how I started when I was 10 I started getting big. I was big like, like I said I was one of the bigger ones, but I was tall so you couldn’t really count it out, and I was, as I sort of, I started to shrink a little bit but just sort of grew in width like. And, it’s more awareness for younger teenagers really, especially. 
GPs who raised the subject of weight gain were sometimes not very tactful: Holly’s GP said “I don’t mean to be blunt but, you know, there is a lot of you”. Holly didn’t think that this was the best way to broach the subject. But she also wondered if she would have taken it seriously if her doctor had been less direct. Steevie also suggested that clinicians need to be ‘nicely blunt’ if they are going to have any impact.
Sometimes a GP drew attention to weight while they were consulting for something else, such as the oral contraceptive pill or even something quite unconnected. This could be a bit embarrassing, especially if they had a friend with them.

If the GP thought there was a weight problem they usually suggested seeing a dietitian. The first step was often to complete a food diary and then the dietitian would suggest changes, provide ideas for recipes or give leaflets about healthy eating. Although some young people liked the dietitian they had seen, others said that it was a waste of time and they had not been told anything they did not already know.

Rachael says the dietitians were friendly enough and kept things light and casual at the...

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Sex: Female
And how did you find them - dietitians, what was their attitude like I suppose?
I guess their attitude was pretty much  the same  every since I really seen them. You know. Like especially the last time the dietitian that I saw wasn’t particularly thin and she kind of went, “I don’t know if I should be doing this job?” You know. And they do, they do try to make light of it. And you know it’s not always just, “You need to lose weight, do it now.” You know it’s not like that.
They’re just there to offer a bit of support and advice. So you can look at things in like a different view.
But yeah. I guess the dietitians have always you know they’ve never been really nasty to me. They’ve never said anything that’s offended me. And they’ve always just tried to make things light and keep things relatively casual. So it wasn’t like too much of a major hoohah really.
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The dietitian Becca saw was rather overweight herself,– which didn't inspire confidence. She wasn't very helpful.

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Age at interview: 17
Sex: Female
I went in and she was quite a large lady, she was, I think she must have been over twenty stone. So not judging or making anything about her it is just the fact that, you know, you think ‘well if she’s a dietitian [laughs] and she’s eating healthily’, and she’s doing what she’s telling me how to become healthy it wasn’t really a positive role model for me, you know, it wasn’t really this is what you can be if you do this you know? So, and I think as well the stuff she was telling me it was stuff I already knew and I wasn’t kind of just, you know, pushing it to one side but she was telling me like the basic kind of eat five fruit and veg a day and exercise thirty minutes for three times a week and things like that, and you know, and she set me like really, they were realistic targets but for three months she said lose two pounds and to me that was a bit of an under-achievement, you know, because, she said, “Because then if you come in and you lose four pounds then that’s great.” And I said, “Yeah but from what I wanted to get out of it wasn’t just to lose two pounds in three months.” You know I wanted to be able to push myself a little bit harder and to actually set myself a target that would make me feel better because for me losing two pounds in three months wouldn’t necessarily make me feel better, you know, it wouldn’t really be an achievement for me and, you know, so yeah I don’t, I don’t really think, I mean she was a lovely lady but it was just, you know, she, she did just cut it, it wasn’t really, I didn’t really get much out of it at all really, you know, so that’s why I didn’t go back because.
What would you have liked her to have done?
Well just, you know, it, like giving me tips on how to overcome overeating and how to change my lifestyle in order to become healthier and things like that and she was just giving me like the basic kind of things I think everyone knows, you know, that like, and so, yeah I think just, just giving me realistic tips and kind of setting me realistic goals that would actually make me feel like I’ve achieved something rather than nothing kind of thing, you know, so yeah I think, I don’t know what she could have done better but to me, I don’t know if I’m just being picky but, you know, to me it just didn’t help me in, in the slightest so yeah, so I just kind of gave up on that idea [laughs] and like carried on myself kind of thing, so yeah. 

Loz sees a dietitian every four months.

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Age at interview: 14
Sex: Female
And does she give you diet sheets?
Loz' Yeah.
Loz' Like with a pie chart on it like for show which foods I should have instead of junk, like fats and sugars and all that.
Loz’s nan' She’s trying to get her to change one thing at a time each time we go, so she’s gotta make one change.
And how often does she go along?
Loz' [Sighs].
Loz’s nan' Roughly about once every three months at the minute.
Loz' once every four months.
And is it easy to make those changes that she asks you to do?
Loz' Yeah.
Yeah? Oh well that’s good. What makes it easy do you think?
Loz' My Nan stopping me.
Said don’t go in the shops.
When Reg was 10 years old she saw a dietitian who upset her a bit by suggesting that her friends might only enjoy being with her because she made them feel  good and slim. She knew this wasn’t true because she’d been friends with several of her group for many years, but she thought it was a strange thing to say and it dented her confidence for a while.
Parents sometimes thought that it was helpful to see a dietician, even if they didn’t hear anything new; they thought it could be useful for their child to hear someone else say what they had been telling them about healthy eating.
Several young people believed that weight problems are often caused by (or complicated by) emotional issues. Becca pointed out that being overweight and anorexia are both connected to emotional problems that cause physical damage and should be approached in the same way. She feels that people are blamed for being overweight and viewed more negatively. Others compared weight problems with addictions such as taking illegal drugs, or smoking.
Sami went for counselling after she broke down in tears in class and her teachers became concerned. She didn’t tell her parents for nearly a year, worried that they would be ashamed of her for needing counselling. Mary said that her daughter didn’t want any of her school mates to know that she was having therapy for her weight problems.

Her year of counselling completely changed her life for the better.

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Sex: Female
And was counselling, did you find counselling helpful?
Absolutely. It changed my life completely. I learnt to talk about everything that I needed to talk about, and some days we would just go in, I had an hour session every week, sometimes it would just be like talking about what I did today, absolutely nothing about my feelings at all, it was just ‘Me time’ for a whole hour. And some days I’d sit there, I’d just cry, sometimes we’d sit there and just listen to music or whatever, and it was really important for me to get to know me and, you know, I really developed myself through that whole year. And I really, I do miss it, but now I realise that that’s the thing that changed me for the better.
Because I had someone to talk to which I never did before.
And how do you think it changed you for the better?
Well I learnt to talk to everyone, like I wouldn’t be able to sit here and talk to you now unless I’d been there, oh, what else, I have spoken to my Dad, I never used to talk to him about it all,  but now I can sit there and I can speak to him, I say, “This is how I’m feeling, this is how I want you to deal with it, ad this is how you should be feeling right now if you are my Dad.” And he’s learnt that, he’s taken that on board now there’s a lot more like compassion between us, like it’s really cool, like I can sit and speak to him if I need to. Whereas I wouldn’t even sit in the same room as him alone like three, four years ago.
My relationship with my boyfriend is a lot better now. Like, I can open up to him a lot more. When we started dating I was like really secretive and depressive all the time. And now we just have so much fun, it’s fabulous. We’re coming up to our three year anniversary next week so that’s brilliant. So I’ve learnt to love me and I’ve learnt to love him as well which is good.
I was not interested in boys, I was not interested in make-up, or high heels, or trying to get into clubs when we’re only 15 years old.
I was just; I had a completely different outlook on life. I just wanted to get somewhere with my life and prove everyone wrong that, you know, a fat person can actually do something good to the world. Like my motto, ever since I changed and ever since I’ve been to counselling was, “I will change this world, I will do something that is gonna make me be remembered.”
Family therapy and individual counselling helped Alex with coping strategies and improved relationships in the family, but the counsellor wasn’t really able to deal with her eating issues. Jezzie saw a counsellor for six months and found that it helped a bit. She found the interaction with the counsellor too formal.

It took Steevie a while to trust her counsellor but he has helped.

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Sex: Female
Not at first, it took me a while to trust him, but just because I mean for 5 years I hadn’t told anyone.
So it took me a, quite a while, and also I didn’t go for the right reasons, I went to shut my friends up basically. And after a while I kind of, I actually had a really bad day, about an hour before I went to see him, so I went to see him and it just kind of all spilled out, and it just kind of kept going from then and that’s when I kind of opened up and carried on opening up, so he was really helpful after a while. He was, I remember one thing, one of the techniques he used was just to say what I’d said to him back to me, but in a different way. And I remember it just sounded so weird, I was thinking, “Did I say that?” And I did, it was just the way he said it was like, oh, and it really kind of opened my mind to mm this isn’t that great; this isn’t the best thing to be doing. One of the things he said to me was, “As a student nurse if you had to deal with a patient that had exactly the same symptoms as you, was doing the same things as you, what would you say?” And I was like, “Why are you asking me that for, you know what I’d say?” I was really annoyed but he was right, he was dead right, and I was like, oh,  “I’d be trying to convince ‘em to stop and I’d say, I’d tell ‘em all the gory details of how it was affecting them and stuff, to try to scare ‘em out of it.” But I, he was just right, it was totally on par with exactly what he should have been saying, but it just kind of like wasn’t nice to hear, ‘I suppose I was in denial.
You said he was sort of saying things to you when you were sort of thinking, “Oh actually maybe that’s not quite…
…the right way to think about things.” Was that the first point where that sort of happened, where you kind of got that sort of change in thinking?
Yeah it was kind of the first point where I, I suppose challenged my ideas. I didn’t really believe him or want to believe him, but I, I could just hear his voice ringing in my head every time I was thinking of certain things or like, looking at how much thinner that girl was, I’d hear him you know ringing in my head, like , “not everyone’s supposed to be that size, or she may be that size but she may have other health problems,” and, you know, just little things he’d say that I’d just kind of start remembering, so I suppose that’s when I started challenging my ideas. 

Jezzie had to address her counsellor by her formal title. She found the whole experience 'intimidating'.

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Sex: Female
I got referred to a counsellor.
For a bit and then it was ok after that.
It was, you mean it stopped after that or?
It stopped after I started talking to my counsellor.
And so what was that like talking to a counsellor about it?
It was a bit intimidating.
In what way?
I don’t like the whole professionalism type thing, of counsellors.
So what was it that put you off about that?
I had to call her Miss something as well. It wasn’t like informal.
It was very formal. That it didn’t help.
Where did she come from, was she …?
She’s from CAMHS [Child and Adolescent Mental Health Services]
So how long did you see her for?
About six months.
How often over that time?
At least once a week.
And did you find it helpful?
How was it helpful?
Well she liked trying to build my self-esteem and stuff, things like that.
How did she do that, what kind of things?
Like, encouraging me to do stuff that would build my confidence and, and talking to me about why I wanted to lose weight. 
Those who attended community based weight loss programmes often really liked being able to talk to someone who listened sympathetically and informally.
See also 'Low moods & depressionand 'Eating disorders -talking therapies'
Weight loss medication
If the weight problem continues despite diet and lifestyle change, some GPs may prescribe a drug (orlistat) that stops the gut from absorbing fat in the diet into the body. In 2009 a health researcher Dr Russell Viner found out that doctors had been prescribing this drug to young people, even though it’s not licensed for under 18s. The same research study found that 45% of young people who took orlistat stopped taking it after one month (possibly because of side effects that include diarrhoea)*. 

After every dieting effort failed, Huw’'s doctor recommended total food replacement therapy, which needs close medical supervision.

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Sex: Male
Recently I took something quite extreme with my diet, I did total food replacement thing, which was a bit, it was recommended by the doctor, because she can understand that I’d been, I’d tried everything else and put my effort into it, and I mean to lose a bit to start and then slowly put it back again, end up heavier which is very demoralising, and so I decided to try a bit of drastic action, which is of course supported by the pharmacy, so it was all safe, and I managed to lose about, just under two and a half stone in a month, which is very good. It’s not something I could do very often though because it’s so difficult, but in some ways it’s easier saying no to everything than no to, no to most things. So I mean you don’t have to, you have the, “Oh”, it’s not, “I can eat that, I can’t eat that.” It’s a, “I can’t eat anything.” Unless it’s a drink of water.
What was it called again?
Lipotrim, okay. So that was a meal substitute?
Yeah it was a total food replacement, replacement course, on a diet. That’s when it had sachets of milk shakes which are made up by the pharmacy, and so it contains everything that I needed in a day, all the calories just without any, without a large amount of calories.
And so it’s it kind of it took away the option of eating, so I wasn’t allowed, so I had two shakes a day, and that then, that was that was it.
And, but tons and tons of water.
And those shakes contained all the protein, carbohydrate minerals, and all that kind of thing that I need, and that we get in food, but they just didn’t have the sugar, the sugar, the fat or the calories.
And so although being incredibly drastic it was very well controlled. I went into see them every week and so it wasn’t, it wasn’t just, “Here you go, have this.” And go at it, it was very well controlled, because otherwise I wouldn’t have done it, because it’s it was so hard to do.
Because it’s so, ‘cos I wouldn’t say no to everything and I could only manage a month before I decided I’m going to step off the bandwagon before I end up cheating. But you’re under a process called Ketosis when you’re body starts eating itself instead of eating food, which although it sounds horrible it’s what you need, and that’s when the weight comes off, and you don’t feel hungry which is quite surprising.
And how soon does your body enter that phase?
It varies because, but for me it’s about a week, and so you get a week of feeling, “I’m really hungry,” and that’s the hard, that’s the horrible thing because all it takes is one chip and you come out of ketosis, and you have to do that week again.
And that’s a, that’s such motivation not to cheat. Because it’s like, “Do I really want to go through that again? No.” 
Some of the people we talked to were wary of taking any weight loss drugs – Rachael was concerned that she might get addicted or end up “crazily thin on these tablets, like one for lunch, dinner and tea”.
Daniel’s father told us that his son had been taking the drug to ‘kick start’ his weight loss and so far it seemed ‘fairly promising’. But Gemma, who later had gastric banding (see below) had a bad reaction to the medicine and ended up in hospital.
Until recently, surgery was not recommended for children under the age of 18 years but The National Institute for Clinical Excellence (NICE) guidelines now say that it may be considered for young people, in exceptional circumstances, if they have been through puberty.
Some of the young people we talked to said that they couldn't imagine they would ever consider surgery for weight loss– it seemed too extreme, or they could not believe their problem could ever be that severe.
Gemma had a gastric band, a surgical procedure that involves fitting a band around the upper part of the stomach. The band divides the stomach in two, creating a smaller pouch at the top. Having this small stomach pouch means that it takes a lot less food to feel full. Gemma’s father had complications after the same surgery 7 years before, which added to her concerns about undergoing surgery. Ten weeks after the surgery she was very pleased to have lost over 4 stone and was feeling much better and more active.

Gemma explains why the decision about whether to have treatment needs to be taken seriously and...

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Sex: Female
It has been one long journey. It’s not been, ah this is fun you know? I knew what I were gonna go through, I watched all the shows I could, I went on all the internet sites I could, spoke to a lot of people from England and America, I did the lot, just to make sure that I were fully aware of what I were doing and, but at my age I mean, it’s summat really, really, really scary. Summat, it wasn’t summat I thought I’d have to go through but it’s done now, can’t go back.
So what were the, tell me what were the reasons against doing it. And what were the reasons for doing it, from your perspective?

The reasons against it is having all the problems my Dad had, like I was I was scared in case it bust open, in case I didn’t wake up from the op. And the pain.  But on the good side, well my nephew, that were, I’m a career girl, I really wanted it for that, and also because I wanted to better my life, and I mean to, if I could better my life by going through with it, and actually achieving losing some weight, then I mean like, put it this way, 14 weeks ago I wouldn’t be doing this.

I wouldn’t be doing it, my confidence has just gone up, I mean I didn’t even go back to college and then I’m three week into it now, I’m back there, I’ve got my head held high, couldn’t care less what anybody’s got to say. I’m sitting outside at break, I’m eating outside, I couldn’t care.
I’m not that little kid hiding hiding in the corner, and like that’s just 14 weeks into it.
And like I’ve already, like it feels like I’ve changed so much already, but there has been a lot of problems like I stopped breathing, I couldn’t breathe after my op, I’ve been back in since ‘cos I couldn’t keep things down, but it’s a journey that you go through and you begin to think, well this is gonna be expected, you know?

I mean, it’s made me more mature and more wise about life and like. If I could help anybody else who’s thinking of it [gastric band surgery] at my age, then I know what I could say well, you know, in a way it’s helped me but it’s not for everybody, you’ve really got to research it before you actually go and do it because it’s not summat you can just think oh right, say “Oh I’m gonna have that done.” You know, you can’t think like that, you’ve gotta really put your head into it, and do that research, ‘cos you if you go in, I mean my Dad, for example, he did not know what he were going in for. And basically when he came out of it, it were like a shock because I mean, yeah he knew what it entailed but he didn’t know fully. Whereas I knew what were gonna happen in surgery ‘cos I’m that gory I had to watch it, ‘cos I knew all about, I knew the after effects.

Because they, I’m not being nasty to everybody but, but not a lot of people are mature enough. They’re not fully aware of what they’re going to be putting their body through, I mean, 17, I still think that I were fully mature enough, but, I knew because I’ve always seen myself as more of an adult than a teenager that I did have the maturity and because I did was, because I were actually watching the programmes and everything, ‘cos of I knew what my Dad had been through, that really helped me so, what I would say to anybody is if you’re thinking about it, just really do your research first. 

And go to appointments because otherwise you’re just gonna be putting yourself in for a big shock. ‘Cos you don’t actually realise how much pain you’re putting yourself through. I mean because like I couldn’t move for 5 days, couldn’t get out of bed, nothing. Like lifting my head up off the bed was a trial for me. It, I mean you always felt like you were going to pass out, didn’t feel comfortable at all.

Gemma describes the after effects of her gastric band surgery, including the vitamin and mineral...

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Sex: Female
Gemma: I can’t eat meat. I, well I can eat lamb but any other meat I’ll be sick. So I can’t eat that, I can hardly eat bread, pasta I can eat a bit, but too much and then you’re sick, so basically now if you go, if you go too overboard, or if summat, or it if don’t agree with you you will get this big almighty pain like someone’s just punched you right in your stomach, and then you’re sick.
Eleven tablets a day?
Gemma’s mum: Yeah.
And what are those tablets for?
Gemma’s mum: There’s Calcogen which is calcium, twice a day. There’s an anti-acid tablet twice a day, ‘cos she kept being sick there’s a sickness tablet three times a day, there’s a multivitamin once a day, she has iron three times a day, and she also has zinc once a day.
And do you have to take those because of the op?
Gemma’s mum: Yes, ‘cos basically, ‘cos they’ve bypassed her small intestine and her large, and her bowel, it don’t absorb all the nutrients. So you’ve got to have more vitamins and all that, but they’ve also told her as well that if she plans to get pregnant she’s got to let ‘em know ‘cos she’ll need double the vitamins and calcium ‘cos the baby’ll take everything.‘Cos it’s like robbing you from all your goodness. So if you don’t get them from your food, you’ve got to get them from supplement, and you need them at double strength so. That’s only the lasses, ‘cos like she has iron three times a day, he only has it once, so I think it’s ‘cos she’s a girl. He only has one lot of iron, she has three.
Charles was a bit surprised to discover that clinicians disagreed over what is the best treatment for his son, Daniel. One suggested a hospital stay where food and exercise would be controlled while another was convinced this would be a bad idea and referred Daniel to the SHINE (Self Help Independent Nutrition and Exercise) programme (see Community-based weight management programmes).

​*This research was carried out by Dr Russell Viner and colleagues from the UCL Institute of Child Health and the University of London. The study was funded from various sources including the Higher Education Funding Council, the NHS, the National Institute of Medical Research and the School of Pharmacy at University College London. The study was peer-reviewed and approved for publication in the British Journal of Clinical Pharmacology.

Last reviewed July 2017.

Last updated July 2017.

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