Obesity Implementing NICE guidance

1. Obesity Implementing NICE guidance 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

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.

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

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

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

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

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

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

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

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 www.cwt.org.uk) guidance on food procurement and healthy catering Involve parents and carers

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

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

14. Key recommendation forself-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

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

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

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

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

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

20. Recommended actions for allhealth 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

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

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

23. Clinical recommendations for the NHS Identification and assessment Management of overweight and obesity in adults and children: • lifestyle changes • drug treatment • surgery

24. 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 Management: lifestyle changes; drug treatment

25. Determine degree of overweight or obesity: adults

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

27. Management: lifestyle changes for adults • Offer multicomponent interventions, including behaviour change strategies to encourage: • increased physical activity • improved eating behaviour • healthy eating

28. Behavioural change strategies: adults • self monitoring of behaviour and progress • stimulus control • goal setting • slowing rate of eating • ensuring social support

29. Behavioural change strategies: adults • 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

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

32. Surgical treatment: adults • Consider surgery if allof 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 psychologicalsupport

33. 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 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 • 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 • 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 • Use clinical judgement to decide when to measure height and weight • Use the UK 1990 BMI charts • Discuss with child/young person and their family

35. Consider intervention or tailored assessment: children

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

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

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

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

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 comorbiditiesChildren 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

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.

42. Costs

43. Savings

44. Access tools online • Costing tools • costing report • costing template • Guide to useful resources • Audit criteria • Available from: www.nice.org.uk/CG043

45. Access the guidance online • Twoquick reference guides –www.nice.org.uk/CG043quickrefguide • NICE guideline – all of the recommendations www.nice.org.uk/CG043niceguideline • Full guideline – all of the evidence and rationale www.nice.org.uk/CG043fullguideline • Two ‘Understanding NICE guidance’ booklets– plain English versions www.nice.org.uk/CG043publicinfo