1. Obesity Implementing NICE guidance December 2006
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DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance to provide a framework for discussion at a local level for a variety of audiences. It can be edited to suit local need. This information does not supersede or replace the guidance itself.
December 2006
NICE clinical guideline 43

2. What this presentation covers:
background
the guidance
key recommendations for prevention
key recommendations for assessment and
management
costs and savings
tools that can help
This presentation covers the background to the guidance, what the guidance covers, the key recommendations, and actions for prevention for key audiences or settings – that is, local authorities and their partners in the community, early years’ providers, schools, workplaces, the NHS and the public; and for the NHS, the key recommendations for assessment and management.
There is information about the costs and savings that are likely to be incurred in implementing the guidance. Finally, the practical support tools available from NICE to support the implementation process are described.

3. Background: changing practice
NICE guidance is based on the best available evidence.
The Department of Health asks NHS organisations to work towards implementing NICE guidance, and compliance will be monitored by the Healthcare Commission.
Other organisations will want to use the guidance to implement best practice.
This guidance includes recommendations for public health audiences and for the public. NICE public health guidance provides guidance on the promotion of good health and the prevention of ill health. The Healthcare Commission will assess the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ issued in July 2004.
Core standard C5 says that nationally agreed guidance should be taken into account when NHS organisations are planning and delivering care. The implementation of NICE public health guidance will help you meet the standards in the seventh domain, such as the core standards C22 and C23 and developmental standard D13
Other organisations will want to use the guidance to implement best practice.
Recommendations can be delivered through local strategic partnerships and community strategy implementation, including the Health, Social Care and Well-being strategies in Wales, as appropriate. They can also be included in local area agreements.
Full implementation of this guideline is likely to take a number of years.

4. Who the guidance is aimed at
local authorities and partners in the community
early years providers
schools
workplaces
self-help, commercial and community programmes
the public
the NHS
The guidance is aimed at professional groups in the health and non-health sectors who share in the prevention and management of overweight and obesity, including:
directors and senior managers and budget holders
professionals working directly with overweight and obese people
professionals in other health and non-health sectors who may have contact with children, young people and adults who are overweight or obese
The recommendations on prevention are grouped according to their key audiences or settings: local authorities and partners in the community, early years’ providers, schools, workplaces, the public and the NHS.
The recommendations for assessment and management are aimed primarily at the NHS.

5. Need for this guidance Rising prevalence of obesity in England
Over 50% of all adults are overweight or obese
Estimated current cost of obesity and overweight is between £6.6 and £7.4 billion annually
In adults, overweight is defined as a body mass index (BMI, which is weight in kilogrammes divided by height in metres squared) of between 25 and 29.9, and obesity as a BMI of 30 or above.
The Health Select Committee (HSC) reported that the cost of obesity in England is between £3.3 and £3.7 billion per year. The HSC estimate includes £49 million for treating obesity, £1.1 billion for treating the consequences of obesity, and indirect costs of £1.1 billion for premature death and £1.45 billion for sickness absence. The cost of obesity plus overweight is estimated at between £6.6 and £7.4 billion per year.
With over half of the population now known to be either overweight or obese, addressing the problem of obesity through primary care management alone is likely to be impossible.

6. Associated comorbidities
Adults
type 2 diabetes
coronary heart disease (CHD)
hypertension
various cancers
osteoarthritis
Children and teenagers
hypertension
hyperinsulinaemia
dyslipidaemia
type 2 diabetes
psychosocial dysfunction
exacerbation of existing conditions
orthopaedic problems
Obesity and overweight have been dubbed a ‘global epidemic’ by the World Health Organization (WHO). Obesity is a condition in which weight gain has reached the point where it poses significant risks to health. Obesity may be considered as a disease in itself and as a risk factor for other diseases.
In adults, obesity is associated with an increased risk of diseases that are a major cause of morbidity and mortality, notably type 2 diabetes, coronary heart disease (CHD), hypertension, various cancers and osteoarthritis.
In children the persistence of obesity into adulthood is the most important concern; the risk of persistence increases with increasing age of the child and the severity of obesity, but obesity also causes significant morbidity in childhood, as indicated.

7. What the guidance covers
Prevention of overweight and obesity in adults and children
Identification and assessment
Management of overweight and obesity in adults
and children:
lifestyle changes
drug treatment
surgery
The guidance:
covers a broad range of non-NHS settings, including local authorities, government agencies, schools and private and voluntary organisations, highlighting their roles in preventing obesity and overweight
covers the care provided by NHS healthcare professionals working with overweight and obese adults and children in primary, secondary and, where appropriate, tertiary care (specialised morbid obesity services)
addresses areas that require collaboration between primary, secondary and tertiary care

8. Prevention and management of obesity is a priority for all
Ensure that preventing and managing obesity is a priority, at both strategic and delivery levels
Dedicate resources for action and training
The prevention and management of obesity should be a priority for all, because of the considerable health benefits of maintaining a healthy weight and the health risks associated with overweight and obesity.
There is an overarching recommendation that as part of their roles in regulation, enforcement and promoting wellbeing, local authorities, primary care trusts (PCTs) or local health boards and local strategic partnerships should ensure that preventing and managing obesity is a priority for action – at both strategic and delivery levels – through community interventions, policies and objectives. Dedicated resources should be allocated for action.
The guidance gives key recommendations for each of the following audiences or settings.
local authorities
early years settings
schools
self-help, commercial and community settings
workplaces
the NHS
This presentation now moves into key recommendations on prevention for each of these audiences which the presenter can ‘cut and paste’ according to audience and local need.

9. Key recommendations for local authorities
Work with local partners to create and manage more safe spaces for incidental and planned physical activity
Address as a priority any concerns around safety, crime and inclusion
Provide facilities and schemes such as cycling and walking routes, cycle parking, area maps and safe play areas
Make streets cleaner and safer, through measures such as traffic calming, congestion charging, pedestrian crossings, cycle routes, lighting and walking schemes
Local authorities should work with local partners, such as industry and voluntary organisations, to create and manage more safe spaces for incidental and planned physical activity, addressing as a priority any concerns about safety, crime and inclusion, by:
providing facilities and schemes such as cycling and walking routes, cycle parking, area maps and safe play areas
making streets cleaner and safer, through measures such as traffic calming, congestion charging, pedestrian crossings, cycle routes, lighting and walking schemes
ensuring buildings and spaces are designed to encourage people to be more physically active (for example, through positioning and signing of stairs, entrances and walkways)
considering in particular people who require tailored information and support, especially inactive, vulnerable groups.

10. Recommended actions for local authorities
All relevant workplace policies should support the local obesity strategy
Work with the local community to identify environmental barriers to eating healthily and being physically active
Ensure building designs encourage the use of stairs and walkways
Encourage local shops and caterers to promote healthy food and drink choices
All relevant workplace policies should support the local obesity strategy by doing the following:
onsite catering should promote healthy food and drink choices (for example by signs, posters, pricing and positioning of products)
physical activity should be promoted through active travel plans, encouraging staff to use stairs, and providing showers and secure bike parking.
For more details of recommendations for workplaces, see recommendations to in the NICE obesity guideline, and page 10 of quick reference guide 1, for local authorities, schools and early years providers, workplaces and the public.
Local authorities need to work in partnership with the local community to identify and address the environmental barriers to eating healthily and being physically active. This can be done through:
Carrying out an audit, involving PCTs, residents, businesses and institutions.
Assessing (ideally by health impact assessments) the impact of policies on people's ability to eat healthily and be physically active. The needs of subgroups such as people of different ages, people from different socioeconomic and ethnic groups, and people with disabilities should be considered.
Local shops and caterers should be encouraged to promote healthy food and drink choices via signs, posters and pricing.

11. Key recommendations for early years settings
Minimise sedentary activities during play time
Provide regular opportunities for enjoyable
active play and structured physical activity sessions
Implement Department for Education and Skills, Food
Standards Agency and Caroline Walker Trust (see
guidance on food procurement and
healthy catering
Involve parents and carers
Nurseries and other childcare facilities should:
Minimise sedentary activities during play time, and provide regular opportunities for enjoyable active play and structured physical activity sessions
Implement guidance on food procurement and healthy catering from the Department for Education and Skills, the Food Standards Agency and the Caroline Walker Trust.
Ensure that children eat regular, healthy meals in a supervised, pleasant, sociable environment, free from distractions such as television. Children should be supervised at mealtimes and, if possible, staff should eat with children.
Involve parents and carers in any activities aimed at preventing excess weight gain and improving children’s diet and activity levels.
For more details of recommendations for early years settings, see recommendations to in the NICE guideline, and page 8 of quick reference guide 1, for local authorities, schools and early years providers, workplaces and the public.

12. Key recommendations for schools
Head teachers and chairs of governors, in collaboration with parents and pupils, should:
assess the whole school environment
ensure school policies help children to eat a
healthy diet, be physically active and maintain a
healthy weight
use a whole-school approach to develop life-long
healthy eating and physical activity
practices
Implementing these recommendations will contribute to meeting the target to halt the annual rise in obesity in children younger than 11 years by 2010, and to implementing the England and Wales National Service Frameworks for children, young people and maternity services (the Children’s NSFs for England and Wales) and ‘Every child matters’ and similar initiatives in Wales. Please refer to the ‘Guide to resources’ implementation document for the links to the relevant websites.
These recommendations also reinforce the guidance on healthy schools already issued by DfES and DH.
Head teachers and chairs of governors, in collaboration with parents and pupils, should assess the whole school environment and ensure that the ethos of all school policies helps children and young people to maintain a healthy weight, eat a healthy diet and be physically active, in line with existing standards and guidance.

13. Recommended actions for schools
Ensure school policies and the school’s environment encourage physical activity and a healthy diet
Teaching, support and catering staff should have training on how to implement healthy school policies
Establish links with health professionals
This includes policies relating to building layout and recreational spaces, catering (including vending machines) and the food and drink that children bring into school, the taught curriculum (including PE), school travel plans and provision for cycling, and policies relating to the National Healthy Schools Programme and extended schools.
Teaching, support and catering staff should have training on how to implement healthy school policies.
Links should be established with health professionals, as well as those involved in local strategies and professional partnerships to promote sports for children and young people.
For more details of recommendations and actions for schools, please refer to recommendations to in the NICE guideline, and to page 9 of quick reference guide 1, for local authorities, schools and early years providers, workplaces and the public.

14. Key recommendation for self-help, commercial and community settings
Primary care organisations and local authorities should recommend to patients, or consider endorsing, self-help, commercial and community weight management programmes only if they follow best practice
Primary care organisations and local authorities should recommend to patients, or consider endorsing, self-help, commercial and community weight management programmes only if they follow best practice, as set out in the next slide.

15. Principles of best practice
Endorse programmes only if they meet best practice standards by:
helping people decide on a realistic healthy target weight
focusing on long-term lifestyle changes
addressing both diet and activity, and offering a variety of approaches
using a balanced, healthy-eating approach
offering practical, safe advice about being more active
including some behaviour-change techniques
recommending and/or providing ongoing support
Weight-loss programmes should be endorsed only if they meet best practice standards by:
helping people decide on a realistic healthy target weight (usually to lose 5–10% of their weight), aiming for a maximum weekly weight loss of between 0.5 and 1 kilogrammes
Focusing on long-term lifestyle changes
addressing both diet and activity, and offering a variety of approaches
using a balanced, healthy-eating approach
offering practical, safe advice about being more active
including some behaviour-change techniques, such as keeping a diary and advice on how to cope with ‘lapses’ and ‘high-risk’ situations
recommending and/or providing ongoing support.

16. Key recommendations for workplaces
Ensure policies encourage activity and healthy eating
Provide opportunities for staff to eat a healthy diet through promotion of healthy choices in restaurants, hospitality, vending machines and shops, in line with Food Standards Agency guidance
The overarching recommendation to workplaces is to ensure that policies encourage activity and healthy eating.
For healthy eating, workplaces should provide opportunities for staff to eat a healthy diet, through:
active and continuous promotion of healthy choices in restaurants, hospitality, vending machines and shops for staff and clients, in line with existing Food Standards Agency guidance

17. Key recommendations for workplaces
Provide opportunities for staff to be physically active through:
working practices and policies, such as active travel policies for staff and visitors
a supportive physical environment, such as improvements to stairwells and providing showers and secure cycle parking
recreational opportunities, such as supporting out-of-hours social activities, lunchtime walks and use of local leisure facilities
Employers can encourage staff to be more physically active in the following ways:
Ensure policies help to increase activity; for example, travel expenses promote walking and cycling to work and between work sites.
Provide showers and secure cycle parking to support active travel.
Improve stairwells to encourage use of stairs.
Support out-of-hours activities such as lunchtime walks and the use of local leisure facilities.
For more details of recommendations for workplaces, see recommendations to in the NICE guideline, and page 10 of quick reference guide 1, for local authorities, schools and early years providers, workplaces and the public.

18. Key recommendations for the NHS
Managers and health professionals in all primary care settings should:
ensure that preventing and managing obesity is a priority, at both strategic and delivery levels
dedicate resources for action and training
consider endorsing, self-help, commercial and community weight management programmes
if they follow best practice
The final bullet point relates to slide 15 which explains principles of best practice, so the presenter may wish include slide 15 after this slide for reference.
The prevention and management of obesity should be a priority for all audiences of this guideline, because of the considerable health benefits of maintaining a healthy weight and the health risks associated with overweight and obesity.
The key priorities for action on prevention in the NHS are as follows:
managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority, at both strategic and delivery levels
dedicated resources should be allocated for action and training
appropriate professionals should be identified who can be trained in the benefits of interventions to prevent obesity, best practice, including tailored support to meet people’s long-term needs, and the use of motivational and counselling techniques
staff should be given the opportunity to foster effective partnerships with a range of organisations, and to develop multidisciplinary teams
The NHS should work with local authorities to ensure that self-help, commercial and community weight-management programmes are recommended only if they meet best practice standards, as listed in slide 15.

19. Recommended actions for the NHS as an employer
Ensure policies encourage activity and healthy eating among staff
Provide showers and secure cycle parking to encourage active travel
Actively promote healthy choices in restaurants
Improve stairwells to encourage use of stairs
Policies should encourage physical activity and healthy eating; for example, travel expenses policies should encourage walking and cycling to work and between work sites.
Showers and secure cycle parking should be provided to encourage active travel. Stairwells should be improved to encourage the use of stairs.
Out-of-hours activities, such as lunchtime walks and the use of local leisure facilities, should be supported.
Healthy choices in restaurants, hospitality, vending machines and shops should be provided, in line with Food Standards Agency advice. For example, use signs, posters, pricing and positioning of products to encourage healthy choices.
Any incentive schemes should be sustained and be part of a wider programme. Examples include travel expenses policies, policies on pricing of food and drink, and contributions to gym membership.
Large organisations:
offer tailored education and promotion programmes to support any action to improve food and drink in the workplace.
if employee health checks are offered, they should address weight, diet and activity, and provide ongoing support.

20. Recommended actions for all health professionals
Offer tailored advice based on individual preferences and needs
Involve parents and carers in actions aimed at children and young adults
Discuss weight, diet and activity at times when weight gain is more likely
Focus interventions on activities that fit easily into everyday life
Use multicomponent interventions
Offer tailored advice based on individual preferences and needs. Provide ongoing support – for example, by phone, post or internet.
Involve parents and carers in actions aimed at children and young adults.
Include promotional, awareness-raising activities as part of long-term interventions, not as one-off activities.
Discuss weight, diet and activity at times when weight gain is more likely, for example:
women – during and after pregnancy or the menopause
anyone who is trying to stop smoking
People often put on weight when giving up smoking, so tell them about services that advise on the prevention and management of obesity if appropriate.
Offer general advice on weight management to people who are concerned about their weight, and encourage increased physical activity.
Focus interventions on activities that fit easily into people’s everyday lives, such as walking.

21. Recommended actions for health professionals in community settings
Support and promote healthy eating and physical activity through retail and catering schemes, schemes and facilities to encourage physical activity, and behavioural change programmes
Support implementation of workplace programmes on obesity
In community programmes, address local concerns, including the availability of services, cost and safety
Support and promote:
retail and catering schemes that promote healthy choices
schemes and facilities that encourage physical activity, including cycling and walking routes (combined with tailored information), based on an audit of local needs
behavioural change programmes and tailored advice to help motivated people to be more physically active; for example, walking or cycling instead of driving or taking the bus.
Support implementation of workplace programmes on obesity
In community programmes to prevent obesity, address concerns about:
the availability of services
the cost of changing behaviour
the taste of healthier foods
the safety of walking and cycling.

22. Recommended actions for health professionals in early years settings
Use a range of components (not just parental education):
offer interactive cookery and physical activity demonstrations
use videos and discussions on meal planning and shopping
provide opportunities for active play
In any programme to prevent obesity in early years and family settings, use a range of components (not just parental education); for example:
diet – offer interactive cookery demonstrations, videos and discussions on meal planning and shopping for food and drink
physical activity – offer interactive demonstrations, videos and group discussions on physical activities, opportunities for active play, safety and local facilities.
In family programmes to prevent obesity, provide ongoing tailored support and incorporate behaviour change techniques.

23. Clinical recommendations for the NHS
Identification and assessment
Management of overweight and obesity in adults and children:
lifestyle changes
drug treatment
surgery
The key clinical recommendations are primarily for the NHS and include:
Identification and assessment of overweight and obesity in adults and children, and the management of overweight and obesity in adults and children, which will include lifestyle changes, and for some drug treatment and surgery
Regular, non-discriminatory long-term follow-up by a trained professional should be offered. Continuity of care in the multidisciplinary team should be ensured through good record keeping.

24. Specialist assessment
Assessment and management: adults
Determine degree of
overweight or obesity
Consider referral
to specialist care
Assess lifestyle,
comorbidities and
willingness to change
Specialist assessment
and management;
surgery and follow up
The care pathway for adults is shown. For further details, see quick reference guide 2 for the NHS, pages 18–19.
Management:
lifestyle changes;
drug treatment

25. Determine degree of overweight or obesity: adults
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
Obesity I
Obesity II
Obesity III
25–29.9
30–34.9
35–39.9
40 or more
Use clinical judgement when interpreting BMI
BMI may be a less accurate measure of adiposity in adults who are highly muscular, so BMI should be interpreted with caution in this group. Some other population groups, such as Asians and older people, have comorbidity risk factors that would be of concern at different BMIs (lower for Asian adults and higher for older people). Healthcare professionals should use clinical judgement when considering risk factors in these groups, even in people not classified as overweight or obese using the given classification.
Waist circumference may be used, in addition to BMI, in people with a BMI less than 35 – please see recommendation in the NICE guideline.

26. Assess lifestyle, comorbidities and willingness to change: adults
Including:
presenting symptoms and underlying causes
of overweight or obesity
willingness to change
risk factors and comorbidities
eating behaviour
lifestyle – diet and physical activity
psychosocial factors
NB: the bullet points in italics in these notes are NOT listed on the slide but you may include these if it is appropriate to do so for your audience.
Factors that need to be assessed include:
presenting symptoms and underlying causes of overweight or obesity
willingness and motivation to change
risk factors and comorbidities – such as type 2 diabetes, hypertension, cardiovascular disease, dyslipidaemia, osteoarthritis and sleep apnoea. Lipid profile, blood glucose (preferably fasting) and blood pressure should be checked
medical problems and medication
eating behaviour
lifestyle – including diet and physical activity
environmental, social and family factors, including family history of overweight and obesity and comorbidities
psychosocial distress
psychological problems
potential of weight loss to improve health

27. Management: lifestyle changes for adults
Offer multicomponent interventions, including behaviour change strategies to encourage:
increased physical activity
improved eating behaviour
healthy eating
Interventions should:
be multicomponent
include behaviour change strategies to increase people’s physical activity levels, and improve their eating behaviour or quality of diet
be delivered by healthcare professionals who have relevant competencies and specific training.

28. Behavioural change strategies: adults
self monitoring of behaviour and progress
stimulus control
goal setting
slowing rate of eating
ensuring social support
Behavioural interventions for adults should include the following strategies, as appropriate for the person:
self monitoring of behaviour and progress
stimulus control
goal setting
slowing rate of eating
ensuring social support
… and
Next slide

29. Behavioural change strategies: adults
problem solving
assertiveness
cognitive restructuring (modifying thoughts)
reinforcement of changes
relapse prevention
strategies for dealing with weight regain
problem solving
assertiveness
cognitive restructuring (modifying thoughts)
reinforcement of changes
relapse prevention
strategies for dealing with weight regain.

30. Referral to specialist care: adults
Consider referral to specialist care if:
underlying causes of overweight and obesity need to be assessed
there are complex disease states and/or needs that cannot be managed adequately in primary or secondary care
conventional treatment has failed
specialist interventions may be needed
drug therapy is being considered for a person with a BMI of 50 kg/m2 or more
surgery is being considered
Consider referral of obese adults to specialist care if:
the underlying causes of overweight or obesity need to be assessed
the person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care
conventional treatment has failed in primary or secondary care
specialist interventions (such as a very-low-calorie diet for extended periods) may be needed
drug therapy is being considered for a person with a BMI of 50 or more or
surgery is being considered.

31. Management: drug treatment for adults
Drug treatment should be considered for adults:
only after dietary and exercise advice have
been started and evaluated
for patients who have not reached their
target weight or have reached a plateau
These recommendations update the NICE
technology appraisals on orlistat and sibutramine
Drug treatment should be considered for patients who have not reached their target weight loss, or have reached a plateau on dietary, activity and behavioural changes alone.
The decision to start drug treatment, and the choice of drug, should be made after discussing with the patient the potential benefits and limitations, including the mode of action, adverse effects and monitoring requirements, and their potential impact on the patient’s motivation. When drug treatment is prescribed, arrangements should be made for appropriate healthcare professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies. Information on patient support programmes should also be provided.
Prescribing should be in accordance with the drug’s summary of product characteristics.
These recommendations for pharmacological interventions for adults update the NICE technology appraisals on orlistat and sibutramine (NICE technology appraisal guidance no. 22 and NICE technology appraisal guidance no. 31); please see section 6 of the NICE guideline for details.
Please see recommendations to and to of the NICE guideline for details on continued prescribing and withdrawal, and on the use of orlistat and sibutramine.

32. Surgical treatment: adults
Consider surgery if all of the following conditions
are met:
the person has a BMI of 40 kg/m² or more, OR
a BMI of 35 to 40 kg/m² plus other significant
disease that could be improved with weight loss
non-surgical measures have failed to achieve or
maintain clinically beneficial weight loss for at
least 6 months
the person has been receiving or will receive
intensive management in a specialist obesity
service, such as psychological support
Consider surgery for people with severe obesity if:
they have a BMI of 40 or more, or between 35 and 40 plus other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
all appropriate non-surgical measures have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
they are receiving or will receive intensive specialist management
they are generally fit for anaesthesia and surgery
they commit to the need for long-term follow-up.
Consider surgery as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 in whom surgical intervention is considered appropriate; consider orlistat or sibutramine before surgery if the waiting time is long.
Surgery should be performed by a multidisciplinary team. The surgeon in the multidisciplinary team should:
have undertaken a supervised training programme
have specialist experience in bariatric surgery
be willing to submit data for a national clinical audit scheme.
Please see recommendations to in the NICE guideline for further details.
The recommendations for surgery update NICE technology appraisal guidance on surgery for people with morbid obesity (NICE technology appraisal guidance no. 46); please see section 6 of the NICE guideline for details.

33. Consider intervention
Assessment and management: children and young people
Determine degree of
overweight or obesity
Consider referral
to an appropriate
specialist
Consider intervention
or assessment
Assessment in
secondary care
Assess lifestyle,
comorbidities and
willingness to change
Specialist
management:
drug treatment;
surgery
The care pathway for children and young people is shown. For further details, see quick reference guide 2 for the NHS, pages 10–12.
Management:
lifestyle changes

34. Determine degree of overweight or obesity: children and young people
Use clinical judgement to decide when to
measure height and weight
Use BMI – UK 1990 BMI charts
Discuss with child/young person and their family
When assessing BMI, relate to UK 1990 BMI charts to give age- and gender-specific information.

35. Consider intervention or tailored assessment: children
BMI
Consider:
91st centile and above
Tailored intervention
98th centile and above
Assessing for comorbidities
After making an initial assessment (see recommendation in the NICE guideline), healthcare professionals should use clinical judgement to investigate comorbidities and other factors at an appropriate level of detail, depending on the person, the timing of the assessment, the degree of overweight or obesity and the results of previous assessments.

36. Assess lifestyle, comorbidities and willingness to change: children
Including:
presenting symptoms and underlying causes
of overweight or obesity,
willingness to change
risk factors and comorbidities
eating behaviours
lifestyle – diet and physical activity
psychosocial factors
NB: the bullet points in italics in these notes are NOT listed on the slide
After measurements have been taken and the issue of weight raised with the child and their family, an assessment should be done, covering:
Presenting symptoms and underlying causes of overweight or obesity
Willingness and motivation to change
Risk factors and comorbidities (such as hypertension, hyperinsulinaemia, dyslipidaemia, type 2 diabetes, psychosocial dysfunction, exacerbation of asthma)
Growth and pubertal status
Eating behaviours
Lifestyle – diet and physical activity
Environmental, social and family factors that may contribute to overweight and obesity and the success of possible treatment
Psychosocial distress, such as low self-esteem, teasing and bullying
Family history of overweight, obesity and comorbidities

37. Management: lifestyle changes for children
Offer multicomponent interventions that include behaviour change strategies to:
increase physical activity levels or decrease
inactivity
improve eating behaviour or quality of diet
Multicomponent interventions are the treatment of choice.
Interventions should include behaviour change strategies (see recommendations and in the NICE guideline) to
Increase children’s physical activity levels or decrease inactivity (recommendations to )
improve eating behaviour and the quality of the child’s diet, and reduce energy intake (recommendations to , and
to )
be delivered by healthcare professionals who have relevant competencies and specific training
aim for either weight maintenance or weight loss, depending on the child’s age and stage of growth.
For further details, see quick reference guide 2 for the NHS, pages 12–14.

38. Behavioural change strategies: children
stimulus control
self monitoring
goal setting
rewards for reaching goals
problem solving
Giving praise and encouraging parents to role-model desired behaviours are also recommended
Behavioural interventions for children should include the following strategies, as appropriate for the child:
stimulus control
self monitoring
goal setting
rewards for reaching goals
problem solving.
Although not strictly defined as behavioural techniques, giving praise and encouraging parents to role-model desired behaviours are also recommended.
For further details, see quick reference guide 2 for the NHS, pages 12–14.

39. Referral to specialist care: children
Consider referral to specialist care if the child has:
significant comorbidity or
complex needs – such as learning or educational difficulties
The recommendation in full is as follows.
In secondary care, the assessment of overweight and/or obese children and young people should include assessment of associated comorbidities and possible aetiology, and investigations such as:
blood pressure measurement
fasting lipid profile
fasting insulin and glucose levels
liver function
endocrine function.
These tests need to be performed, and results interpreted, in the context of the degree of overweight and obesity, the child’s age, history of comorbidities, possible genetic causes, and any family history of metabolic disease related to overweight and obesity.

40. Management: drug treatment for children
Consider drug treatment only if multicomponent dietary,
exercise and behavioural approaches have been started
and evaluated.
Children under 12: drug treatment not generally recommended.
Prescribe only in exceptional circumstances such as severe
life-threatening comorbidities Children over 12: drug treatment is recommended only if
there are severe comorbidities
Prescribing should be started by a specialist multidisciplinary
team with experience of prescribing for this age group
Consider drug treatment only after dietary, exercise and behavioural approaches have been started and evaluated.
For children younger than 12 years:
drug treatment is not generally recommended
prescribe only in exceptional circumstances, if there are severe life-threatening comorbidities (such as sleep apnoea or raised intracranial pressure)
prescribing should be started and monitored only in specialist paediatric settings.
For children aged 12 years and older:
drug treatment is recommended only if there are physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities
prescribing should be started by a specialist multidisciplinary team with experience of prescribing for this age group.
Multidisciplinary teams prescribing orlistat or sibutramine should have expertise in:
drug monitoring
psychological support
behavioural interventions
interventions to increase physical activity
Interventions to improve diet.
Please refer to recommendations to and of the NICE guideline for information on continued prescribing and withdrawal
These recommendations for pharmacological interventions for update the NICE technology appraisal guidance on orlistat and sibutramine (NICE technology appraisal guidance no. 22 and NICE technology appraisal guidance no. 31); please see section 6 of the NICE guideline for details.

41. Surgical treatment: young people
Surgery is not generally recommended
for children or young people.
However, in exceptional circumstances
it may be considered for young people.
Surgery is not generally recommended for children or young people.
Consider surgery for young people only in exceptional circumstances, and if:
they have achieved or nearly achieved physiological maturity
they have a BMI of 40 or more, or a BMI between 35 and 40 and other significant disease (for example, diabetes, high blood pressure) that could be improved if they lost weight
all appropriate non-surgical measures have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
they are receiving or will receive intensive specialist management
they are generally fit for anaesthesia and surgery
they commit to the need for long-term follow-up.
Discuss with the young person and their family in detail the potential benefits, long-term implications and risks, including complications and perioperative mortality.
Do a comprehensive psychological, education, family and social assessment before performing the surgery.
Carry out a full medical evaluation, including genetic screening to exclude rare, treatable causes of the obesity.
Choose the intervention jointly with the young person, taking into account:
the degree of obesity
comorbidities
evidence on effectiveness and long-term effects
the facilities and equipment available
the experience of the surgeon who would perform the operation.
Please see recommendations to and to in the NICE guideline for details about how surgery should be performed, and care during and after the operation
The recommendations for surgery update the NICE technology appraisal guidance on surgery for people with morbid obesity (NICE technology appraisal guidance no. 46); please see section 6 of the NICE guideline for details.

42. Costs Recommendations with a significant resource impact
Annual costs £000s
Recurrent costs
Treatment of overweight/obese children with comorbidities
10,686
Bariatric surgery for obese adults with BMI above 50 kg/m2
23,880
Non-recurrent costs
Appropriate training in obesity management
28,756
TOTAL ESTIMATED COSTS
63,321
Shown are the likely national costs of implementing the guideline recommendations that have a significant resource impact. See the costing report for further details.

43. Savings Recommendations with a significant resource impact
Annual costs £000s
Cash-releasing savings
Reduced prescription costs in primary care
–13,992
Opportunity savings
Reduced GP contacts
–41,636
TOTAL ESTIMATED SAVINGS
–55,628
Shown are potential savings that could be achieved nationally as a result of implementing the guideline recommendations that have a significant resource impact. See the costing report for further details.

44. Access tools online Costing tools costing report costing template
Guide to useful resources
Audit criteria
Available from:
NICE has developed tools to help organisations implement this guidance, which can be found on the NICE website.
Costing tools
Costing report to estimate the national savings and costs associated with implementation
Costing template to estimate the local costs and savings involved
A guide to useful resources to support implementation
Audit criteria to monitor local practice

45. Access the guidance online
Two quick reference guides –
NICE guideline – all of the recommendations
Full guideline – all of the evidence and rationale
Two ‘Understanding NICE guidance’ booklets – plain English versions
The guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guides or ‘Understanding NICE guidance’ by calling the NHS Response Line on and quoting the appropriate reference number.
There are two quick reference guides: QRG1, for local authorities, schools and early years providers, workplaces and the public (reference number N1152), and QRG2, for the NHS (N1154).
There are also two ‘Understanding NICE guidance’ booklets, entitled ‘Preventing obesity and staying a healthy weight’ (reference number N1153) and ‘Treatment for people who are overweight or obese’ (N1155).
Please refer to the accompanying ‘Guide to Resources to Support Implementation’.