Obesity Implementing NICE guidance December 2006 NICE clinical

Obesity Implementing NICE guidance December 2006 NICE clinical guideline 43

What this presentation covers: • background • the guidance • key recommendations for prevention • • key recommendations for assessment and management costs and savings • tools that can help

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.

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

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

Associated comorbidities Children and teenagers Adults • type 2 diabetes • coronary heart disease (CHD) • hypertension • various cancers • osteoarthritis • • • hypertension hyperinsulinaemia dyslipidaemia type 2 diabetes psychosocial dysfunction • exacerbation of existing conditions • orthopaedic problems

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

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

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

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

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

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

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

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

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

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

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-ofhours social activities, lunchtime walks and use of local leisure facilities

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

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

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

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

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

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

Assessment and management: adults Determine degree of overweight or obesity Consider referral to specialist care Assess lifestyle, comorbidities and willingness to change Management: lifestyle changes; drug treatment Specialist assessment and management; surgery and follow up

Determine degree of overweight or obesity: adults Classification BMI (kg/m 2) Healthy weight 18. 5– 24. 9 Overweight 25– 29. 9 Obesity I 30– 34. 9 Obesity II 35– 39. 9 Obesity III 40 or more Use clinical judgement when interpreting BMI

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

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

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

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

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/m 2 or more • surgery is being considered

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

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

Assessment and management: children and young people Determine degree of overweight or obesity Consider intervention or assessment Assess lifestyle, comorbidities and willingness to change Management: lifestyle changes Consider referral to an appropriate specialist Assessment in secondary care Specialist management: drug treatment; surgery

Determine degree of overweight or obesity: children and young people • Use clinical judgement to decide when to measure height and weight • Use the BMIUK – UK 1990 BMI charts • Discuss with child/young person and their family

Consider intervention or tailored assessment: children BMI Consider: 91 st centile and above Tailored intervention 98 th centile and above Assessing for comorbidities

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

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

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

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

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

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.

Costs Recommendations with a significant resource impact Annual costs £ 000 s Recurrent costs Treatment of overweight/obese children with comorbidities 10, 686 Bariatric surgery for obese adults with BMI above 50 kg/m 2 23, 880 Non-recurrent costs Appropriate training in obesity management 28, 756 TOTAL ESTIMATED COSTS 63, 321

Savings Recommendations with a significant resource impact Annual costs £ 000 s Cash-releasing savings Reduced prescription costs in primary care – 13, 992 Opportunity savings Reduced GP contacts – 41, 636 TOTAL ESTIMATED SAVINGS – 55, 628

Access tools online Costing tools • costing report • costing template Guide to useful resources Audit criteria Available from: www. nice. org. uk/CG 043

Access the guidance online Two quick reference guides – www. nice. org. uk/CG 043 quickrefguide NICE guideline – all of the recommendations www. nice. org. uk/CG 043 niceguideline Full guideline – all of the evidence and rationale www. nice. org. uk/CG 043 fullguideline Two ‘Understanding NICE guidance’ booklets – plain English versions www. nice. org. uk/CG 043 publicinfo