Obesity

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

• Children and teenagers
• hypertension
• hyperinsulinaemia
• dyslipidaemia
• type 2 diabetes
• psychosocial dysfunction
• exacerbation of existing conditions
• orthopaedic problems

• Adults
• type 2 diabetes
• coronary heart disease (CHD)
• hypertension
• various cancers
• osteoarthritis

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 schools
  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 managementadults
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 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

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 treatmentyoung 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

• Two quick reference guides www.nice.org.uk/CG043q
  uickrefguide
• 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/CG043public
  info