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Obesity overview

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Obesity

About

What is covered

This pathway covers the prevention, identification, assessment and management of obesity in adults and children. The pathway aims to:
  • stem the rising prevalence of obesity and diseases associated with it
  • increase the effectiveness of interventions to prevent people becoming overweight and obese
  • improve the care provided to adults and children with obesity, particularly in primary care.

Updates

Updates to this pathway

14 April 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to surgery for overweight and obese children and young people and surgery for obese adults.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
12 March 2015 Update on publication of Preventing excess weight gain (NICE guideline NG7).
26 November 2014 Update on publication of obesity (NICE guideline CG189).
26 November 2013 Implantation of a duodenal–jejunal bypass sleeve for managing obesity (NICE interventional procedure guidance 471) added.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Guiding principles

The recommendations in this pathway should be undertaken in parallel, wherever possible as part of a system-wide approach to preventing obesity. Ideally, to be as cost effective as possible, they should be implemented as part of integrated programmes that address the whole population, but with a scale and intensity that is proportionate to addressing locally identified inequalities in obesity and associated diseases and conditions.
The guidance provides a framework for existing NICE guidance (community based or individual interventions) that directly or indirectly impacts on obesity prevention or management.
Other NICE guidance can also be used to ensure effective delivery of the recommendations made in this guidance (see community engagement, behaviour change and cultural appropriateness below).

Community engagement

The prerequisites for effective community engagement are covered in NICE's pathway on community engagement. These include:

Behaviour change

The prerequisites for effective interventions and programmes aimed at changing behaviour are covered in NICE's pathway on behaviour change. In summary, NICE recommends that interventions and programmes should be based on:
  • careful planning, taking into account the local and national context and working in partnership with recipients
  • a sound knowledge of community needs
  • existing skills and resources, by identifying and building on the strengths of individuals and communities and the relationships within communities.
In addition, interventions and programmes should be evaluated, either locally or as part of a larger project, and practitioners should be equipped with the necessary competencies and skills to support behaviour change. This includes knowing how to use evidence-based tools. (NICE recommends that courses for practitioners should be based on theoretically informed, evidence-based best practice.)

Cultural appropriateness

The prerequisites for culturally appropriate action are outlined in the NICE pathway on preventing type 2 diabetes. The guidance emphasises that culturally appropriate action takes account of the community's cultural or religious beliefs and language and literacy skills by:
  • Using community resources to improve awareness of, and increase access to, interventions. For example, they involve community organisations and leaders early on in the development stage, use media, plan events or make use of festivals specific to black and minority ethnic groups.
  • Understanding the target community and the messages that resonate with them.
  • Identifying and addressing barriers to access and participation, for example, by keeping costs low to ensure affordability, and by taking account of different working patterns and education levels.
  • Developing communication strategies that are sensitive to language use and information requirements. For example, they involve staff who can speak the languages used by the community. In addition, they may provide information in different languages and for varying levels of literacy (for example, by using colour-coded visual aids and the spoken rather than the written word).
  • Taking account of cultural or religious values, for example, the need for separate physical activity sessions for men and women, or in relation to body image, or beliefs and practices about hospitality and food. They also take account of religious and cultural practices that may mean certain times of the year, days of the week, settings, or timings are not suitable for community events or interventions. In addition, they provide opportunities to discuss how interventions would work in the context of people's lives.
  • Considering how closely aligned people are to their ethnic group or religion and whether they are exposed to influences from both the mainstream and their community in relation to diet and physical activity.

Principles of weight management for children and young people

Assessing the body mass index (BMI) of children is more complicated than for adults because it changes as they grow and mature. In addition, growth patterns differ between boys and girls.
Thresholds that take into account a child's age and sex are used to assess whether their BMI is too high or too low. These are usually derived from a reference population, known as a child growth reference, with the data presented in BMI centile charts. In a clinical assessment, a child or young person on or above the 98th centile is classified as obese. A child or young person on or above the 91st centile, but below the 98th centile, is classified as overweightSeveral classification systems are used in the UK to define 'obesity' and 'overweight' in children. In the analysis of population surveys such as the National Child Measurement Programme and the Health Survey for England (HSE), children over the 85th centile, and on or below the 95th centile, are classified as being 'overweight'. Children over the 95th centile are classified as being 'obese'. However, the NCMP uses the clinical cut-off points described above when providing feedback about the BMI of individual children to parents and carers..
When monitoring and comparing groups of children and young people BMI z scores may be used. BMI z score is a measure of how many standard deviations a child or young person's BMI is above or below the average BMI for their age and gender. (This is based on a reference population known as a child growth reference.) For instance, a z score of 1.5 indicates that a child is 1.5 standard deviations above the average value, and a z score of -1.5 indicates a child is 1.5 standard deviations below the average value.
The advantage of using BMI z scores, instead of BMI, is that it allows direct comparison of BMI (and any changes in BMI) across different ages and by gender. This term is sometimes used interchangeably with 'BMI standard deviation score' (BMI SDS).
In this pathway, the term BMI centile is used in recommendations that focus on working with individual children or young people. BMI z score is used in recommendations relating to monitoring and research.
Further information can be found in A simple guide to classifying body mass index in children.

Lifestyle weight management for overweight and obese children and young people

Lifestyle weight management services

In this pathway, lifestyle weight management services (sometimes called tier 2 services) refers to services that help people in a particular geographical location who are overweight or obese. The service can be made up of 1 or more lifestyle weight management programmes. The programmes are usually based in the community and may be run by the public, private or voluntary sector.

Lifestyle weight management programmes

In this pathway, lifestyle weight management programmes refers to programmes that focus on diet, physical activity, behaviour-change or any combination of these elements.
Many of these programmes aim to maintain the growing child's existing weight in the short term, as they grow taller. This is an appropriate short-term aim, because it will result in an improved BMI over time, and is often described as 'growing into their weight'.
Young people who are overweight or obese and are no longer growing taller will ultimately need to lose weight to improve their BMI. However, preventing further weight gain while they gain the knowledge and skills they need to make lifestyle changes, may be an appropriate short-term aim. These changes then need to become firmly established habits over the long term.
Providers of lifestyle weight management programmes are private, public or voluntary sector organisations offering lifestyle weight management services in the community or in (or via) primary care settings.

Commissioning lifestyle weight management services for overweight and obese children and young people

Clinical commissioning groups

Clinical commissioning groups (CCGs) are responsible for commissioning a range of healthcare services for children and adults. This includes specialist obesity services (sometimes called tier 3 services). The groups do not directly commission lifestyle weight management services (sometimes called tier 2 services). Rather, they work with local authorities to coordinate and integrate planning and commissioning through the health and wellbeing board.

Health and wellbeing boards

Health and wellbeing boards are based in upper tier and unitary local authorities. They aim to improve health and care services and the health and wellbeing of local people. They bring together key commissioners in the locality, including representatives of clinical commissioning groups, public health, children's services and adult social services. They include at least 1 elected councillor and a representative of HealthWatch. The board develops a health and wellbeing strategy for the local area. This is based on an assessment of local needs, including a joint strategic needs assessment.

Local authority commissioners

Local authorities commission some public health services for children and young people aged 5–19 years. They have a mandatory responsibility to deliver the National Child Measurement Programme. They also commission non-mandatory services such as school nursing and community-based weight management services.

NHS England

NHS England commissions primary care, clinical and specialised services. It also commissions public health services for children aged 0–5 years (including health visiting and much of the Healthy Child Programme). In 2015 the organisation's public health services transfer to local authorities.

Public Health England

Public Health England is an executive agency of the Department of Health. It provides advice and expertise to local authorities, NHS England and clinical commissioning groups on the commissioning of public health services.

Physical activity and sedentary behaviour

Physical activity

Physical activity includes the full range of human movement. It includes everyday activities such as walking or cycling for everyday journeys, active play, work-related activity, active recreation (such as working out in a gym), dancing, gardening or playing active games, as well as organised and competitive sport.

Sedentary behaviour

Sedentary behaviour describes activities that do not increase energy expenditure much above resting levels. Sedentary activities include sitting, lying down and sleeping. Associated activities, such as watching television, are also sedentary.

Short Text

The prevention, identification, assessment and management of obesity in adults and children

What is covered

This pathway covers the prevention, identification, assessment and management of obesity in adults and children. The pathway aims to:
  • stem the rising prevalence of obesity and diseases associated with it
  • increase the effectiveness of interventions to prevent people becoming overweight and obese
  • improve the care provided to adults and children with obesity, particularly in primary care.

Updates

Updates to this pathway

14 April 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to surgery for overweight and obese children and young people and surgery for obese adults.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
12 March 2015 Update on publication of Preventing excess weight gain (NICE guideline NG7).
26 November 2014 Update on publication of obesity (NICE guideline CG189).
26 November 2013 Implantation of a duodenal–jejunal bypass sleeve for managing obesity (NICE interventional procedure guidance 471) added.

Quality standards

Quality statements

Vending machines

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults using vending machines in local authority and NHS venues can buy healthy food and drink options.

Rationale

The environment in which people live influences their ability to achieve and maintain a healthy weight. Local authorities and NHS organisations can set an example by providing healthy food and drink choices at their venues. They can influence venues in the community (such as leisure centres) and services provided by commercial organisations to have a positive impact on the diet of adults using them.

Quality measures

Structure
Evidence that local authorities and NHS organisations provide, or make contractual arrangements for the provision of, healthy food and drink options in any vending machines in their venues.
Data source: Local data collection.
Process
Proportion of local authority and NHS venues with vending machines that contain healthy food and drink options.
Numerator – the number in the denominator that have vending machines that contain healthy food and drink options.
Denominator – the number of local authority and NHS venues with vending machines.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that any vending machines in their venues offer healthy food and drink options.

What the quality statement means for adults

Adults have a choice of healthy food and drink options available from vending machines in local authority and NHS venues such as hospitals, clinics and leisure centres.

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink
Food and drink that helps people to follow Public Health England’s eatwell plate advice, and that does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives.
[Expert consensus]

Nutritional information at the point of choosing food and drink options

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults see details of nutritional information on menus at local authority and NHS venues.

Rationale

Providing details about the nutritional content of food will allow people to make an informed choice when choosing meals. This information will help people achieve or maintain a healthy weight by enabling them to manage their daily nutritional intake.

Quality measures

Structure
Evidence that local authorities and NHS organisations ensure that information on the nutritional content of meals is included on menus at venues.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that their venues provide details about the nutritional content of menu items.

What the quality statement means for adults

Adults selecting meals in catering facilities in local authority and NHS venues such as hospitals, clinics and leisure centres have information on the nutritional content of meals to help them choose.

Source guidance

Definitions of terms used in this quality statement

Nutritional information
This includes details on the calorie content of meals as well as information on the fat, saturated fat, salt and sugar content. If the nutritional value of recipes is not known, ingredients should be listed and cooking methods described.
[Adapted from expert consensus and Type 2 diabetes prevention (NICE guideline PH35), recommendation 8]

Equality and diversity considerations

Information needs to be available in a variety of languages and formats to ensure that it is accessible to people of all ages and meets the needs of the community. Nutritional information should be available in a variety of formats appropriate to the target audience. The format of this information should be suitable for people with sensory impairment.

Prominent placement of healthy options

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults see healthy food and drink choices displayed prominently in local authority and NHS venues.

Rationale

Local authorities and NHS organisations can set an example by ensuring that healthy food and drink choices are promoted in their venues. Prominent positioning will help to ensure that people will consider healthier options when they are choosing food and drink.

Quality measures

Structure
Evidence that local authority and NHS venues make arrangements to display healthy food and drink options in prominent positions.
Data source: Local data collection.
Outcome
Sales of healthy food and drink options.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that healthy food and drink choices are displayed in prominent positions in their venues.

What the quality statement means for adults

Adults can easily find healthy foods and drinks when using catering facilities in local authority or NHS venues such as hospitals, clinics and leisure centres.

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink choices
Food and drink that helps people to meet Public Health England’s eatwell plate advice, and that does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives.
[Expert consensus] 

Maintaining details of local lifestyle weight management programmes

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults have access to a publicly available, up-to-date list of local lifestyle weight management programmes.

Rationale

Effective lifestyle weight management programmes for adults can be delivered by a range of organisations and in different locations. The local authority should maintain an up-to-date list of local lifestyle weight management programmes and make it available to the public. Raising awareness of locally provided programmes is important to ensure that the public know about the programmes in their area and how to enrol in them. Increased public awareness may lead to more self-referrals to these programmes.

Quality measures

Structure
Evidence that an up-to-date list of local lifestyle weight management programmes for adults is publicly available.
Data source: Local data collection.
Outcome
Number of self-referrals of overweight or obese adults to locally commissioned lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes, commissioners and local authorities

Providers of lifestyle weight management programmes ensure that they provide local authorities with up-to-date information about local lifestyle weight management programmes for overweight and obese adults.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that information about lifestyle weight management programmes is available across all health and care services.
Local authorities ensure that they maintain a publicly available, up-to-date list of local lifestyle weight management programmes for overweight and obese adults.

What the quality statement means for adults

Adults can easily find information about lifestyle weight management programmes in their area and how to enrol in them.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
List of local lifestyle weight management programmes
The list should include details of programmes that have been commissioned by the local authority or clinical commissioning group and other public, private or voluntary evidence-based programmes.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]

Equality and diversity considerations

Local authorities should take into account the cultural and communication needs of the local population when providing a publicly accessible list of local lifestyle weight management programmes.

Publishing performance data on local lifestyle weight management programmes

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults can access data on attendance, outcomes and views of participants and staff from locally commissioned lifestyle weight management programmes.

Rationale

It is important that providers of lifestyle weight management programmes measure outcomes of the programmes and make the results available. This will allow commissioners and the general public to monitor and evaluate particular programmes to assess whether they are meeting their objectives and providing value for money. This ensures that any issues with the programmes are identified as early as possible, so that the programmes can be improved, leading to better outcomes for adults using the programmes. It will also help adults to select lifestyle weight management programmes.

Quality measures

Structure
a) Evidence that commissioners and providers of lifestyle weight management programmes jointly agree the key performance indicators to be collected for monitoring and evaluation.
Data source: Local data collection.
b) Evidence that commissioners and providers of lifestyle weight management programmes have used data from monitoring and evaluation to amend and improve programmes.
Data source: Local data collection.
Process
a) Proportion of adults recruited to a locally commissioned lifestyle weight management programme who have information on attendance, outcomes and views of participants and staff collected at recruitment and completion.
Numerator – the number in the denominator who have information on attendance, outcomes and views of participants and staff collected at recruitment and completion.
Denominator – the number of adults recruited to a locally commissioned lifestyle weight management programme.
Data source: Local data collection.
b) Proportion of adults who complete a lifestyle weight management programme who have data on outcomes collected 6 months after completion of the programme.
Numerator – the number in the denominator who have data on outcomes collected 6 months after completion of the programme.
Denominator – the number of adults who complete a lifestyle weight management programme.
Data source: Local data collection.
c) Proportion of adults who complete a lifestyle weight management programme who have data on outcomes collected 1 year after completion of the programme.
Numerator – the number in the denominator who have data on outcomes collected 1 year after completion of the programme.
Denominator – the number of adults who complete a lifestyle weight management programme.
Data source: Local data collection.
Outcome
Improved performance of local lifestyle weight management programmes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as local authorities and providers of lifestyle weight management programmes) ensure that they publish data on attendance, outcomes and views of participants and staff. Providers of lifestyle weight management programmes should use the data to monitor and evaluate their programmes. Data sharing should be in line with the Department of Health’s information governance and data protection requirements.
Healthcare professionals (such as GPs, dietitians and practice nurses) consider data on attendance, outcomes and views of participants and staff for local lifestyle weight management programmes before offering information or a referral.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) agree key performance indicators for lifestyle weight management programmes providers, and ensure the data are published. Commissioners use the data on attendance, outcomes and views of participants and staff to improve local provision of lifestyle weight management services.

What the quality statement means for adults

Adults can find published information about their local lifestyle weight management programmes, including how many people enrol in them, how much weight people lose and how good people think the programme is.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
Data on attendance, outcomes and views of participants and staff
Providers of lifestyle weight management programmes should use the standard evaluation framework for weight management programmes and validated tools to monitor interventions.
As a minimum, information on participants at the end of the programme should be collected and assessed, in line with the Department of Health's Best practice criteria for weight management services. Details of how each participant’s weight has changed 12 months after the programme is completed should also be collected.
[Weight management: lifestyle services for overweight or obese adults (2014) NICE guideline PH53, recommendation 17]

Equality and diversity considerations

When monitoring and evaluating lifestyle weight management programmes, information also needs to be collected on the programmes’ suitability for minority groups, for example groups with different family origins or religions and groups with disabilities. Reasonable adaptations should be made to the programmes to make them accessible to these groups and to assess their impact on health inequalities.

Raising awareness of lifestyle weight management programmes

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults identified as being overweight or obese are given information about local lifestyle weight management programmes.

Rationale

When adults are identified as being overweight or obese it is important that they are given information about local lifestyle weight management programmes. Actively raising the possibility of participation in one of these programmes will support people who choose to take positive action to lose weight by self-referring to a suitable programme.

Quality measures

Structure
Evidence of local arrangements to give adults who are identified as being overweight or obese information about local lifestyle weight management programmes.
Data source: Local data collection.
Process
Proportion of adults identified as being overweight or obese who are given information about local lifestyle weight management programmes.
Numerator – the number in the denominator who are given information about local weight management programmes.
Denominator – the number of adults identified as being overweight or obese.
Data source: Local data collection. Data on BMI values are included in the Health and Social Care Information Centre care.data extract.
Outcome
a) Number of self-referrals of overweight or obese adults to lifestyle weight management programmes.
Data source: Local data collection.
b) Obesity prevalence.
Data source: Local data collection.
c) Prevalence of obesity-related comorbidities.
Data source: Local data collection. The numbers of people with type 2 diabetes, hypertension and coronary heart disease are shown in the Quality and outcomes framework indicators DM001, HYP001 and CHD001.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.
Healthcare professionals (such as GPs, practice nurses, secondary healthcare professionals, dietitians and community pharmacists) ensure that they provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that they commission services that provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.

What the quality statement means for adults

Adults who are overweight or obese are given information about local lifestyle weight management programmes, including what the programmes involve and how to take part.

Source guidance

Definitions of terms used in this quality statement

Adults who are overweight or obese
Adults are assessed to see if they are overweight or obese using their body mass index (BMI). The following table shows the cut-off points for a healthy weight or being overweight or obese.
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
25.0–29.9
Obesity I
30.0–34.9
Obesity II
35.0–39.9
Obesity III
40.0 or more
BMI is a less accurate indicator of adiposity in adults who are highly muscular, so it should be interpreted with caution in this group.
Waist circumference can also be used to assess whether someone is at risk of health problems because they are overweight or obese (up to a BMI of 35 kg/m2). For men, a waist circumference of less than 94 cm is low risk, 94–102 cm is high risk and more than 102 cm is very high risk. For women, a waist circumference of less than 80 cm is low risk, 80–88 cm is high risk and more than 88 cm is very high risk.
Using lower BMI thresholds to trigger action to reduce the risk of conditions such as type 2 diabetes has been recommended for adults of black African, African-Caribbean or Asian family origin. The lower thresholds are 23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk.

Equality and diversity considerations

Service providers and healthcare professionals should take into account the cultural and communication needs of people who are overweight or obese when giving information about lifestyle weight management programmes.
Healthcare professionals should ensure that people of black African, African-Caribbean or Asian family origin who have higher comorbidity risk factors are given information about lifestyle weight management programmes if they have a BMI of 23 kg/m2 or more.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to participate. This includes using a respectful and non-judgemental approach to engage people. Particular attention should be given to people who may be less likely to participate, such as people with learning difficulties or mental health problems and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy.

Referral to a lifestyle weight management programme for people with comorbidities

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults identified as overweight or obese with comorbidities are offered a referral to a lifestyle weight management programme.

Rationale

It is important for general practice teams and other healthcare professionals to offer a referral to a local lifestyle weight management programme to adults who are overweight or obese with comorbidities in order to improve their health outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are identified as overweight or obese with comorbidities are offered a referral to a lifestyle weight management programme.
Data source: Local data collection.
Process
Proportion of adults who are identified as overweight or obese with comorbidities who are referred to a lifestyle weight management programme.
Numerator – the number in the denominator who are referred to a lifestyle weight management programme.
Denominator – the number of adults who are identified as overweight or obese with comorbidities.
Data source: Local data collection.
Outcome
a) Number of adults who are identified as overweight or obese with comorbidities enrolling in lifestyle weight management services.
Data source: Local data collection.
b) Obesity prevalence among adults with comorbidities.
Data source: Local data collection.
c) Obesity-related comorbidities
Data source: Local data collection. The number of people with type 2 diabetes, hypertension and coronary heart disease is shown in the Quality and outcomes framework indicators DM001, HYP001 and CHD001.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as local authorities and providers of lifestyle weight management programmes) ensure that a referral to a locally commissioned suitable lifestyle weight management programme is offered to adults who are identified as overweight or obese and who have comorbidities.
Healthcare professionals (such as GPs, practice nurses and dietitians) offer a referral to a locally commissioned lifestyle weight management programme to adults who are identified as overweight or obese and who have comorbidities.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that adults who are identified as overweight or obese and who have comorbidities are offered a referral to a locally commissioned lifestyle weight management programme and that there is sufficient capacity to meet demand.

What the quality statement means for adults

Adults who are overweight or obese and have other conditions such as type 2 diabetes, high blood pressure, high cholesterol, arthritis, heart disease or sleep apnoea are offered a referral to a local lifestyle weight management programme to help them improve their overall health.

Source guidance

Definitions of terms used in this quality statement

Adults who are overweight or obese
Adults are assessed to see if they are overweight or obese using their body mass index (BMI). The following table shows the cut-off points for a healthy weight or being overweight or obese.
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
25.0–29.9
Obesity I
30.0–34.9
Obesity II
35.0–39.9
Obesity III
40.0 or more
BMI is a less accurate indicator in adults who are highly muscular, so it should be interpreted with caution in this group.
Waist circumference can also be used to assess whether someone is at risk of health problems because they are overweight or obese (up to a BMI of 35 kg/m2). For men, a waist circumference of less than 94 cm is low risk, 94–102 cm is high risk and more than 102 cm is very high risk. For women, a waist circumference of less than 80 cm is low risk, 80–88 cm is high risk and more than 88 cm is very high risk.
Using lower BMI thresholds to trigger action to reduce the risk of conditions such as type 2 diabetes has been recommended for adults of black African, African–Caribbean and Asian family origin. The lower thresholds are 23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk.
Adults with comorbidities
Adults with any other comorbidities in addition to being overweight or obese, such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea.
[Adapted from Obesity: identification, assessment and management (2014) NICE guideline CG189]

Equality and diversity considerations

Healthcare professionals should take into account the cultural and communication needs of adults who are overweight or obese with comorbidities when making a referral to a lifestyle weight management programme.
Healthcare professionals should ensure that people of black African, African-Caribbean or Asian family origin are offered a referral to a lifestyle weight management programme if they have a BMI of 23 kg/m2 or more because of their increased health risk.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to participate. This includes using a respectful and non-judgemental approach. Particular attention should be given to engaging people who may be less likely to participate, such as people with learning difficulties or mental health problems and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy.

Preventing weight regain

This quality statement is taken from the obesity in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.

Rationale

It is important to ensure that adults who are about to complete a lifestyle weight management programme have a plan to help them maintain a healthy weight and avoid weight regain. This will enable them to self-manage their weight and make it less likely that they will need further lifestyle weight management interventions in the future.

Quality measures

Structure
Evidence of local arrangements to ensure that adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.
Data source: Local data collection.
Process
Proportion of adults completing a lifestyle weight management programme who agree a plan to prevent weight regain.
Numerator – the number in the denominator who agree a plan to prevent weight regain.
Denominator – the number of adults about to complete a lifestyle weight management programme.
Data source: Local data collection.
Outcome
a) Obesity prevalence.
Data source: Local data collection.
b) Prevalence of obesity-related comorbidities.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (providers of lifestyle weight management programmes) ensure that adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.
Healthcare professionals (such as GPs, dietitians and practice nurses) ensure that they make referrals to and promote lifestyle weight management programmes that include agreeing a plan to prevent weight regain on completion.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that a plan to prevent weight regain is agreed with adults who are about to complete a lifestyle weight management programme. This could be provided by the lifestyle weight management programme provider or commissioned separately.

What the quality statement means for adults

Adults who are about to finish a lifestyle weight management programme agree a plan to help them avoid putting weight back on.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
Plan to prevent weight regain
A plan to prevent weight regain should:
• encourage independence and self-management (including self-monitoring)
• identify a suitable weight target that is sustainable in the long term
• identify sources of ongoing support once the programme has ended, such as online resources, support groups, other local services or activities, and family and friends
• include goals to maintain new dietary habits and increased physical activity levels and strategies to overcome any difficulties encountered
• identify dietary habits that will support weight maintenance and are sustainable in the long term
• promote ways of being more physically active and less sedentary which are sustainable in the long term.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendations 9 and 10]

Equality and diversity considerations

Providers of lifestyle weight management programmes should take into account the cultural and communication needs of people who are completing a lifestyle weight management programme when agreeing a plan to prevent weight regain.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to agree a plan to prevent weight regain. This includes using a respectful and non-judgemental approach. Particular attention should be given to engaging people with learning difficulties or mental health issues and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy when developing a plan to prevent weight regain.

Vending machines

This quality statement is taken from the obesity prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, using vending machines in local authority and NHS venues can buy healthy food and drink options.

Rationale

The environment in which people live influences their ability to achieve and maintain a healthy weight. Local authorities and NHS organisations can set an example by providing healthy food and drink choices at their venues. They can influence venues in the community (such as leisure centres) and services provided by commercial organisations to have a positive impact on the diet of children and young people using them. Legal requirements govern the provision of food in local authority-maintained schools (see the Department of Education’s Standards for school food in England for further details). Schools are therefore not covered by this quality statement.

Quality measures

Structure
Evidence that local authorities and NHS organisations provide, or make contractual arrangements for the provision of, healthy food and drink options in any vending machines in their venues that are used by children and young people.
Data source: Local data collection.
Process
Proportion of local authority and NHS venues used by children and young people with vending machines that have vending machines that contain healthy food and drink options.
Numerator – the number in the denominator that have vending machines that contain healthy food and drink options.
Denominator – the number of local authority and NHS venues used by children and young people with vending machines.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that any vending machines in their venues that are used by children and young people offer healthy food and drink options.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) have a choice of healthy food and drink options available from vending machines in local authority and NHS venues (for example hospitals, clinics and leisure centres).

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink
Food and drink that helps people to meet the eatwell plate guidance recommendations, and which does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives. [Expert consensus]

Nutritional information at the point of choosing food and drink options

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, see details of nutritional information on menus at local authority and NHS venues.

Rationale

Providing details about the nutritional content of food will allow children and young people (and their parents or carers) to make an informed choice when choosing meals. This information will help people achieve or maintain a healthy weight by enabling them to manage their daily nutritional intake.

Quality measures

Structure
Evidence that local authorities and NHS organisations ensure that information on the nutritional content of meals is included on menus at venues that are used by children and young people.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that their venues used by children and young people provide details about the nutritional content of menu items.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) selecting meals in catering facilities in local authority and NHS venues have information on the nutritional content of meals to help them choose.

Source guidance

Definitions of terms used in this quality statement

Nutritional information
This includes details on the calorie content of meals as well as information on the fat, saturated fat, salt and sugar content. If the nutritional value of recipes is not known, ingredients should be listed and cooking methods described. [Adapted from expert consensus and NICE guideline PH35, recommendation 8]

Equality and diversity considerations

Information needs to be available in a variety of languages and formats to ensure that it is accessible to people of all ages and meets the needs of the community. Nutritional information should be available in a variety of formats appropriate to the target audience. The format of this information should be suitable for children and young people with sensory impairment.

Prominent placement of healthy options

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, see healthy food and drink choices displayed prominently in local authority and NHS venues.

Rationale

Local authorities and NHS organisations can set an example by ensuring that healthy food and drink choices are promoted in their venues. Prominent positioning will help to ensure that children and young people (and their parents or carers) will consider healthier options when they are choosing food and drink.

Quality measures

Structure
Evidence that local authority and NHS venues used by children and young people make arrangements to display healthy food and drink options in prominent positions.
Data source: Local data collection.
Outcome
Sales of healthy food and drink options.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that healthy food and drink choices are displayed in prominent positions in their venues.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) can easily find healthy foods and drinks when using catering facilities in local authority or NHS venues.

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink choices
Food and drink that helps people to meet the eatwell plate guidance recommendations, and which does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives. [Expert consensus] 

Maintaining details of local lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, have access to a publicly available up to date list of local lifestyle weight management programmes.

Rationale

Effective lifestyle weight management programmes for children and young people can be delivered by a range of organisations, in different locations, covering different age groups. The local authority should maintain an up-to-date list of local lifestyle weight management programmes and make it available to the public. Raising awareness of these locally provided programmes is important to ensure that the public, healthcare professionals and other professionals who work with children and young people are aware of the programmes that exist in their area and how to access them. Increased public awareness may lead to more self referrals to the programmes, either by children and young people themselves or their parents or carers. In addition, raised awareness among healthcare professionals such as GPs, school nurses, health visitors and staff involved in the National Child Measurement Programme and the Healthy Child Programme may lead to more direct referrals.

Quality measures

Structure
Evidence that an up to date list of local lifestyle weight management programmes for children and young people is made publically available by the local authority.
Data source: Local data collection.
Outcome
Number of referrals (including self referrals, by children and young people or their parents or carers) to lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes, healthcare professionals, other professionals who work with children and young people, and local authorities

Providers of lifestyle weight management programmes ensure that they provide local authorities with up to date lists of local lifestyle weight management programmes for children and young people.
Healthcare professionals (such as GPs, dietitians, pharmacists, health visitors, school nurses and staff involved in the National Child Measurement Programme) and other professionals who work with children and young people (such as youth workers, social workers and pastoral care workers, and those who work in schools, colleges, early years organisations, children’s centres and looked-after children’s teams) ensure that they are aware of the lifestyle weight management programmes for children and young people in their area and how to enrol people on them.
Local authorities ensure that they maintain a publicly available up-to-date list of local lifestyle weight management programmes for children and young people.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) are aware of the lifestyle weight management programmes in their area and how they can enrol on them.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Raising awareness of lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people identified as being overweight or obese, and their parents or carers as appropriate, are given information about local lifestyle weight management programmes.

Rationale

Actively raising the possibility of participation in a local lifestyle weight management programme will help to increase the use of these programmes by children and young people identified as being overweight or obese.

Quality measures

Structure
Evidence of written protocols and local arrangements for healthcare professionals and other professionals to give information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).
Data source: Local data collection.
Process
Proportion of children and young people identified as being overweight or obese, and their parents or carers as appropriate, who are given information about local lifestyle weight management programmes.
Numerator – the number in the denominator who are given information about local lifestyle weight management programmes.
Denominator – the number of children and young people identified as being overweight or obese, and their parents or carers as appropriate.
Data source: Local data collection.
Outcome
Number of children and young people enrolling in lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for healthcare professionals, other professionals who work with children and young people, and commissioners

Healthcare professionals (such as GPs, dietitians, pharmacists, health visitors, school nurses and staff involved in the National Child Measurement Programme) and other professionals who work with children and young people (such as youth workers, social workers and pastoral care workers, and those who work in schools, colleges, early years organisations, children’s centres and looked after children’s teams) ensure that they provide information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that healthcare professionals, and other professionals who work with children and young people, provide information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).

What the quality statement means for children and young people and their parents or carers

Children and young people identified as being overweight or obese (and their parents or carers, as appropriate) are given information about local lifestyle weight management programmes, including an explanation of what the programmes involve and how to take part.

Source guidance

Definitions of terms used in this quality statement

Information about local lifestyle weight management programmes
This information should explain what these programmes involve and how people can take part (including whether or not they can self refer). [Adapted from NICE guideline PH47, recommendation 7]
Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]
Other professionals who work with children and young people
These professionals include youth workers, social workers and pastoral care workers, as well as those who work in schools, colleges, early years organisations, children’s centres and looked after children’s teams. [NICE guideline PH47, recommendation 7] 

Family involvement in lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Family members or carers of children and young people are invited to attend lifestyle weight management programmes, regardless of their weight.

Rationale

Family members and carers have an important role and responsibility in influencing the environment in which children and young people live. Therefore, actively involving family members and carers in the programme is important to ensure that children and young people receive positive reinforcement and support away from the programme. Involving the family and carers is also likely to make the programme more successful, change behaviour and lifestyle choices and improve BMI over time in children and young people. It may also benefit family members because they may have the same genetic and/or lifestyle risk factors for weight.

Quality measures

Structure
Evidence that providers of lifestyle weight management programmes for children and young people invite family members or carers to attend, regardless of their weight.
Data source: Local data collection.
Process
Proportion of children and young people who attend a lifestyle weight management programme whose family members or carers have been invited to attend.
Numerator – the number in the denominator whose family members or carers have been invited to attend.
Denominator – the number of children and young people who attend a lifestyle weight management programme.
Data source: Local data collection.

Outcome

Family member attendance and involvement in lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes, healthcare professionals and public health practitioners, and local authorities

Providers of lifestyle weight management programmes for children and young people ensure that they involve family members and carers in the programme and provide services that include the appropriate core components. Weight management programmes should emphasise the importance, and highlight the benefit, of family member involvement and encouragement.
Healthcare professionals and public health practitioners who deliver lifestyle weight management programmes for children and young people encourage the involvement of family members or carers.
Local authorities ensure that they commission lifestyle weight management programmes for children and young people that encourage family members and carers to be actively involved and contain the core components to involve family members. Local authorities require providers to report on how they have engaged family members and carers in the programme as part of their performance management and contract monitoring.

What the quality statement means for families or carers

Family members or carers of children and young people identified as being overweight or obese are encouraged to be involved in the child’s lifestyle weight management programme, regardless of their own weight. This may include receiving training and resources to support changes in behaviour or, if this is not possible, being provided with information on the aims of the programme. Family members are also encouraged to eat healthily and to be physically active, regardless of their weight.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Equality and diversity considerations

Particular consideration needs to be given when engaging adult men in the programmes because they are often harder to involve than other family members. Consideration also needs to be given to the language needs of the child or young person accessing the programme, as well as their family members or carers. For some families, the child or young person may be the only English speaker in the family.

Evaluating lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, can access data on attendance, outcomes and the views of participants and staff from lifestyle weight management programmes.

Rationale

It’s important that providers of lifestyle weight management programmes for children and young people measure outcomes of the programmes and make the results available. This will allow commissioners and the general public to monitor and evaluate particular programmes to assess whether they are meeting their objectives and providing value for money. This ensures that any issues with the programmes are identified as early as possible, so that the programmes can be improved, leading to better outcomes for children and young people using the programmes. It will also help children and young people, and their parents or carers, to select lifestyle weight management programmes.

Quality measures

Structure
a) Evidence that commissioners and providers of lifestyle weight management programmes for children and young people jointly agree the key performance indicators to be collected for monitoring and evaluation.
Data source: Local data collection.
b) Evidence that commissioners and providers of lifestyle weight management programmes for children and young people have used data from monitoring and evaluation to amend and improve programmes.
Data source: Local data collection.
Process
a) Proportion of children and young people recruited to a lifestyle weight management programme that has data on attendance, outcomes and the views of participants and staff collected at recruitment and completion.
Numerator – the number in the denominator that has data on attendance, outcomes and the views of participants and staff collected at recruitment and completion.
Denominator – the number of children and young people recruited to a lifestyle weight management programme.
Data source: Local data collection.
b) Proportion of children and young people who complete a lifestyle weight management programme that has data on outcomes collected at 6 months after completion of the programme.
Numerator – the number in the denominator that has data on outcomes collected at 6 months after completion of the programme.
Denominator – the number of children and young people who complete a lifestyle weight management programme.
Data source: Local data collection.
c) Proportion of children and young people who complete a lifestyle weight management programme that has data on outcomes collected at 1 year after completion of the programme.
Numerator – the number in the denominator that has data on outcomes collected at 1 year after completion of the programme.
Denominator – the number of children and young people who complete a lifestyle weight management programme.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes and commissioners

Providers of lifestyle weight management programmes for children and young people ensure that they collect and report data to monitor and evaluate the programme.
Commissioners (including directors of public health, public health teams, local authority commissioners and clinical commissioning groups) ensure that sufficient resources are dedicated to monitoring and evaluation, that they evaluate lifestyle weight management programmes for children and young people using data on outcomes, and use the data to amend and improve the programme.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) attend lifestyle weight management programmes that are regularly monitored and evaluated so that the programmes can be improved.

Source guidance

Definitions of terms used in this quality statement

Data on attendance, outcomes and the views of participants and staff
The data to be collected include:
  • Numbers recruited, percentage completing the programme and percentage followed up at 6 months and at 1 year after completing the programme.
  • For all those recruited, BMI and BMI z score measured at:
    • recruitment
    • completion of the programme
    • 6 months after completing the programme
    • 1 year after completing the programme.
  • referral routes
  • outcomes related to the aim of the programme and related to factors that can support or contribute to a reduction in BMI, for example:
    • improvements in diet
    • improvements in physical activity
    • reduction in sedentary behaviour
    • improvements in self-esteem.
  • variations in outcomes, according to age, gender, ethnicity and socioeconomic status
  • views of participants (including children, young people and their families and/or carers who have participated in the programme, as well as those who did not complete the programme)
  • views of staff delivering the programme. [Adapted from (NICE guideline PH47, recommendations 2 and 15]
(See Public Health England’s Standard evaluation framework for weight management interventions for examples of other possible outcome measures.)

Lifestyle weight management programme

Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Equality and diversity considerations

When monitoring and evaluating lifestyle weight management programmes, information also needs to be captured to ensure that the programmes are suitable for minority groups, for example, by family origin, religion and disability, and that reasonable adaptations are being made to the programmes to make them accessible to these groups and to assess their impact on health inequalities.

Reducing sedentary behaviour: placeholder statement

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence based guidance to be developed in this area.

Rationale

Decreasing the levels of sedentary behaviour in children and young people is a different issue to increasing physical activity in this group, as noted in Start active, stay active: a report on physical activity from the four home countries' Chief Medical Officers. There is a need to specify interventions and actions that can be carried out to achieve a reduction in sedentary behaviour in children and young people and also methods that can be used to easily and successfully measure sedentary activity.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Guiding principles

The recommendations in this pathway should be undertaken in parallel, wherever possible as part of a system-wide approach to preventing obesity. Ideally, to be as cost effective as possible, they should be implemented as part of integrated programmes that address the whole population, but with a scale and intensity that is proportionate to addressing locally identified inequalities in obesity and associated diseases and conditions.
The guidance provides a framework for existing NICE guidance (community based or individual interventions) that directly or indirectly impacts on obesity prevention or management.
Other NICE guidance can also be used to ensure effective delivery of the recommendations made in this guidance (see community engagement, behaviour change and cultural appropriateness below).

Community engagement

The prerequisites for effective community engagement are covered in NICE's pathway on community engagement. These include:

Behaviour change

The prerequisites for effective interventions and programmes aimed at changing behaviour are covered in NICE's pathway on behaviour change. In summary, NICE recommends that interventions and programmes should be based on:
  • careful planning, taking into account the local and national context and working in partnership with recipients
  • a sound knowledge of community needs
  • existing skills and resources, by identifying and building on the strengths of individuals and communities and the relationships within communities.
In addition, interventions and programmes should be evaluated, either locally or as part of a larger project, and practitioners should be equipped with the necessary competencies and skills to support behaviour change. This includes knowing how to use evidence-based tools. (NICE recommends that courses for practitioners should be based on theoretically informed, evidence-based best practice.)

Cultural appropriateness

The prerequisites for culturally appropriate action are outlined in the NICE pathway on preventing type 2 diabetes. The guidance emphasises that culturally appropriate action takes account of the community's cultural or religious beliefs and language and literacy skills by:
  • Using community resources to improve awareness of, and increase access to, interventions. For example, they involve community organisations and leaders early on in the development stage, use media, plan events or make use of festivals specific to black and minority ethnic groups.
  • Understanding the target community and the messages that resonate with them.
  • Identifying and addressing barriers to access and participation, for example, by keeping costs low to ensure affordability, and by taking account of different working patterns and education levels.
  • Developing communication strategies that are sensitive to language use and information requirements. For example, they involve staff who can speak the languages used by the community. In addition, they may provide information in different languages and for varying levels of literacy (for example, by using colour-coded visual aids and the spoken rather than the written word).
  • Taking account of cultural or religious values, for example, the need for separate physical activity sessions for men and women, or in relation to body image, or beliefs and practices about hospitality and food. They also take account of religious and cultural practices that may mean certain times of the year, days of the week, settings, or timings are not suitable for community events or interventions. In addition, they provide opportunities to discuss how interventions would work in the context of people's lives.
  • Considering how closely aligned people are to their ethnic group or religion and whether they are exposed to influences from both the mainstream and their community in relation to diet and physical activity.

Principles of weight management for children and young people

Assessing the body mass index (BMI) of children is more complicated than for adults because it changes as they grow and mature. In addition, growth patterns differ between boys and girls.
Thresholds that take into account a child's age and sex are used to assess whether their BMI is too high or too low. These are usually derived from a reference population, known as a child growth reference, with the data presented in BMI centile charts. In a clinical assessment, a child or young person on or above the 98th centile is classified as obese. A child or young person on or above the 91st centile, but below the 98th centile, is classified as overweightSeveral classification systems are used in the UK to define 'obesity' and 'overweight' in children. In the analysis of population surveys such as the National Child Measurement Programme and the Health Survey for England (HSE), children over the 85th centile, and on or below the 95th centile, are classified as being 'overweight'. Children over the 95th centile are classified as being 'obese'. However, the NCMP uses the clinical cut-off points described above when providing feedback about the BMI of individual children to parents and carers..
When monitoring and comparing groups of children and young people BMI z scores may be used. BMI z score is a measure of how many standard deviations a child or young person's BMI is above or below the average BMI for their age and gender. (This is based on a reference population known as a child growth reference.) For instance, a z score of 1.5 indicates that a child is 1.5 standard deviations above the average value, and a z score of -1.5 indicates a child is 1.5 standard deviations below the average value.
The advantage of using BMI z scores, instead of BMI, is that it allows direct comparison of BMI (and any changes in BMI) across different ages and by gender. This term is sometimes used interchangeably with 'BMI standard deviation score' (BMI SDS).
In this pathway, the term BMI centile is used in recommendations that focus on working with individual children or young people. BMI z score is used in recommendations relating to monitoring and research.
Further information can be found in A simple guide to classifying body mass index in children.

Lifestyle weight management for overweight and obese children and young people

Lifestyle weight management services

In this pathway, lifestyle weight management services (sometimes called tier 2 services) refers to services that help people in a particular geographical location who are overweight or obese. The service can be made up of 1 or more lifestyle weight management programmes. The programmes are usually based in the community and may be run by the public, private or voluntary sector.

Lifestyle weight management programmes

In this pathway, lifestyle weight management programmes refers to programmes that focus on diet, physical activity, behaviour-change or any combination of these elements.
Many of these programmes aim to maintain the growing child's existing weight in the short term, as they grow taller. This is an appropriate short-term aim, because it will result in an improved BMI over time, and is often described as 'growing into their weight'.
Young people who are overweight or obese and are no longer growing taller will ultimately need to lose weight to improve their BMI. However, preventing further weight gain while they gain the knowledge and skills they need to make lifestyle changes, may be an appropriate short-term aim. These changes then need to become firmly established habits over the long term.
Providers of lifestyle weight management programmes are private, public or voluntary sector organisations offering lifestyle weight management services in the community or in (or via) primary care settings.

Commissioning lifestyle weight management services for overweight and obese children and young people

Clinical commissioning groups

Clinical commissioning groups (CCGs) are responsible for commissioning a range of healthcare services for children and adults. This includes specialist obesity services (sometimes called tier 3 services). The groups do not directly commission lifestyle weight management services (sometimes called tier 2 services). Rather, they work with local authorities to coordinate and integrate planning and commissioning through the health and wellbeing board.

Health and wellbeing boards

Health and wellbeing boards are based in upper tier and unitary local authorities. They aim to improve health and care services and the health and wellbeing of local people. They bring together key commissioners in the locality, including representatives of clinical commissioning groups, public health, children's services and adult social services. They include at least 1 elected councillor and a representative of HealthWatch. The board develops a health and wellbeing strategy for the local area. This is based on an assessment of local needs, including a joint strategic needs assessment.

Local authority commissioners

Local authorities commission some public health services for children and young people aged 5–19 years. They have a mandatory responsibility to deliver the National Child Measurement Programme. They also commission non-mandatory services such as school nursing and community-based weight management services.

NHS England

NHS England commissions primary care, clinical and specialised services. It also commissions public health services for children aged 0–5 years (including health visiting and much of the Healthy Child Programme). In 2015 the organisation's public health services transfer to local authorities.

Public Health England

Public Health England is an executive agency of the Department of Health. It provides advice and expertise to local authorities, NHS England and clinical commissioning groups on the commissioning of public health services.

Physical activity and sedentary behaviour

Physical activity

Physical activity includes the full range of human movement. It includes everyday activities such as walking or cycling for everyday journeys, active play, work-related activity, active recreation (such as working out in a gym), dancing, gardening or playing active games, as well as organised and competitive sport.

Sedentary behaviour

Sedentary behaviour describes activities that do not increase energy expenditure much above resting levels. Sedentary activities include sitting, lying down and sleeping. Associated activities, such as watching television, are also sedentary.

Supporting information

Offer regular, non-discriminatory long-term follow-up by a trained professional. Ensure continuity of care in the multidisciplinary team through good record-keeping.
Do not use bioimpedance as a substitute for BMI as a measure of general adiposity.
Make an initial assessment, then use clinical judgement to investigate comorbidities and other factors to 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.
Manage comorbidities when they are identified; do not wait until the person has lost weight.
Offer people who are not yet ready to change the chance to return for further consultations when they are ready to discuss their weight again and willing or able to make lifestyle changes. Give them information on the benefits of losing weight, healthy eating and increased physical activity.
Recognise that surprise, anger, denial or disbelief about their health situation may diminish people's ability or willingness to change. Stress that obesity is a clinical term with specific health implications, rather than a question of how people look; this may reduce any negative feelings.
During the consultation:
  • Assess the person's view of their weight and the diagnosis, and possible reasons for weight gain.
  • Explore eating patterns and physical activity levels.
  • Explore any beliefs about eating and physical activity and weight gain that are unhelpful if the person wants to lose weight.
  • Be aware that people from certain ethnic and socioeconomic backgrounds may be at greater risk of obesity, and may have different beliefs about what is a healthy weight and different attitudes towards weight management.
  • Find out what the person has already tried and how successful this has been, and what they learned from the experience.
  • Assess the person's readiness to adopt changes.
  • Assess the person's confidence in making changes.
Give people and their families and/or carers information on the reasons for tests, how the tests are done and their results and meaning. If necessary, offer another consultation to fully explore the options for treatment or discuss test results.
Multicomponent interventions are the treatment of choice. Ensure weight management programmes include behaviour change strategies to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet and reduce energy intake. (See behaviour change in adults and behaviour change in children in this pathway for more information.)
When choosing treatments, take into account:
  • the person's individual preference and social circumstance and the experience and outcome of previous treatments (including whether there were any barriers)
  • the person's level of risk, based on BMI and, where appropriate, waist circumference (see identifying people who are overweight or obese in this pathway).
  • any comorbidities.
Document the results of any discussion. Keep a copy of the agreed goals and actions (ensure the person also does this), or put this in the person's notes.
Offer support depending on the person's needs, and be responsive to changes over time.
Ensure any healthcare professionals who deliver interventions for weight management have relevant competencies and have had specific training.
Provide information in formats and languages that are suited to the person. Use everyday, jargon-free language and explain any technical terms when talking to the person and their family or carers. Take into account the person's:
  • age and stage of life
  • gender
  • cultural needs and sensitivities
  • ethnicity
  • social and economic circumstances
  • specific communication needs (for example because of learning disabilities, physical disabilities or cognitive impairments due to neurological conditions).
Praise successes – however small – at every opportunity, to encourage the person through the difficult process of changing established behaviour.
Give people who are overweight or obese, and their families and/or carers, relevant information on:
  • being overweight and obesity in general, including related health risks
  • realistic targets for weight loss (for adults see the NICE pathway on lifestyle weight management services for overweight or obese adults)
  • the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; advise them that the change from losing weight to maintenance typically happens after 6–9 months of treatment
  • realistic targets for outcomes other than weight loss, such as increased physical activity and healthier eating
  • diagnosis and treatment options
  • healthy eating in general (more information on healthy eating can be found at NHS Choices)
  • medication and side effects
  • surgical treatments
  • self-care
  • voluntary organisations and support groups and how to contact them.
Ensure there is adequate time in the consultation to provide information and answer questions.
If a person (or their family or carers) do not feel this is the right time for them to take action, explain that advice and support will be available in the future whenever they need it. Provide contact details so that the person can get in touch when they are ready.
Total energy content (kJ) divided by total weight (grams). Energy density can be calculated for individual foods, drink or for dietary intake as a whole. Lower energy dense foods, drinks or meals provide fewer calories per gram than higher energy dense foods, drinks or meals. High energy dense foods tend to be higher in fat or sugar and include crisps, nuts, confectionery, biscuits, cakes, full fat cheese and meat products. Low energy dense foods tend to be higher in water and lower in fat or sugar and include fruit and vegetables, soups and stews.
Extend the use of lower BMI thresholds to trigger action to prevent type 2 diabetes among black African and African-Caribbean populations.
Deliver any behavioural intervention with the support of an appropriately trained professional.
Tailor dietary changes to food preferences and allow for a flexible and individual approach to reducing calorie intake.
Do not use unduly restrictive and nutritionally unbalanced diets, because they are ineffective in the long term and can be harmful.
Encourage people to improve their diet even if they do not lose weight, because there can be other health benefits.
Consider pharmacological treatment only after dietary, exercise and behavioural approaches have been started and evaluated.
Pharmacological treatment may be used to maintain weight loss, rather than to continue to lose weight.
If there is concern about micronutrient intake adequacy, a supplement providing the reference nutrient intake for all vitamins and minerals should be considered, particularly for vulnerable groups such as older people (who may be at risk of malnutrition) and young people (who need vitamins and minerals for growth and development).
Offer support to help maintain weight loss to people whose drug treatment is being withdrawn; if they did not reach their target weight, their self-confidence and belief in their ability to make changes may be low.
Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:
  • They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and 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 been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss.
  • The person has been receiving or will receive intensive management in a tier 3 service. (For more information on tier 3 services, see NHS England's report on joined up clinical pathways for obesity.)
  • The person is generally fit for anaesthesia and surgery.
  • The person commits to the need for long-term follow-up.
Provide regular, specialist postoperative dietetic monitoring, including:
  • information on the appropriate diet for the bariatric procedure
  • monitoring of the person's micronutrient status
  • information on patient support groups
  • individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance.
Arrange prospective audit so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term. (The National Bariatric Surgery Registry is now available to conduct national audit for a number of agreed outcomes.)
The surgeon in the multidisciplinary team should:
  • have had a relevant supervised training programme
  • have specialist experience in bariatric surgery
  • submit data for a national clinical audit scheme. (The National Bariatric Surgery Registry is now available to conduct national audit for a number of agreed outcomes.)
The hospital specialist and/or bariatric surgeon should discuss the following with people who are severely obese if they are considering surgery to aid weight reduction:
  • the potential benefits
  • the longer-term implications of surgery
  • associated risks
  • complications
  • perioperative mortality.
The discussion should also include the person's family, as appropriate.
Choose the surgical intervention jointly with the person, taking into account:
  • the degree of obesity
  • comorbidities
  • the best available evidence on effectiveness and long-term effects
  • the facilities and equipment available
  • the experience of the surgeon who would perform the operation.

WHO advice on BMI public health action points for Asian populations (World Health Organization 2004)

White European populations
Asian populations
Description
Less than 18.5 kg/m2
Less than 18.5 kg/m2
underweight
18.5–24.9 kg/m2
18.5–23 kg/m2
increasing but acceptable risk
25–29.9 kg/m2
23–27.5 kg/m2
increased risk
30 kg/m2 or higher
27.5 kg/m2 or higher
high risk

International guidance on BMI/waist circumference thresholds

International Diabetes Federation guidance on waist circumference thresholds as a measure of central obesity (Alberti et al. 2007)

European
Men
94 cm (37 inches)
Women
80 cm (31.5 inches)
South Asians
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Chinese
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Japanese
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Ethnic south and central Americans
Use south Asian recommendations until more specific data are available
Sub-Saharan Africans
Use European data until more specific data are available
Eastern Mediterranean and middle east (Arab) populations
Use European data until more specific data are available
Other guidance is available from:
  • Scottish Intercollegiate Guidelines Network (2010)
  • Ministry of Health India (Misra et al. 2009)
  • Ministry of Health Singapore (Health Promotion Board Singapore 2005)
  • Obesity in Asia Collaboration (2007)
  • Cooperative meta-analysis group of the working group on obesity in China (Zhou 2002)
The following recommendations are from NICE diagnostics guidance on depth of anaesthesia monitors.
The use of EEG-based depth of anaesthesia monitors is recommended as an option during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The BIS depth of anaesthesia monitor is therefore recommended as an option in these patients.
The use of EEG-based depth of anaesthesia monitors is also recommended as an option in all patients receiving total intravenous anaesthesia. The BIS monitor is therefore recommended as an option in these patients.
Although there is greater uncertainty of clinical benefit for the E-Entropy and Narcotrend-Compact M depth of anaesthesia monitors than for the BIS monitor, the Committee concluded that the E-Entropy and Narcotrend-Compact M monitors are broadly equivalent to BIS. These monitors are therefore recommended as options during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The E-Entropy and Narcotrend-Compact M monitors are also recommended as options in patients receiving total intravenous anaesthesia.
Anaesthetists using EEG-based depth of anaesthesia monitors should have appropriate training and experience with these monitors and understand the potential limitations of their use in clinical practice.

Glossary

electroencephalography
Bispectral Index
childhood and puberty close monitoring
body mass index is defined as a person's weight in kilograms divided by the square of their height in metres and is reported in units of kg/m2. Specific cut-off points are used to assess whether a person is a healthy weight, underweight, overweight or obese. For children and young people these are related to age and gender
the process of getting communities involved in decisions that affect them. This includes the planning, development and management of services, as well as activities that aim to improve health or reduce health inequalities (see Community engagement for health improvement: questions of definition, outcomes and evaluation – a background paper prepared for NICE by Professor Jenny Popay [2006])
this includes the food and drink (including alcoholic drinks) consumed, energy and nutrient intake, portion size and the pattern and timing of eating
when energy intake from all food and drink (measured as calories or kilojoules) matches energy used for all bodily functions and physical activity. If energy intake is higher than energy used, a person will gain weight. If energy intake is less than energy used, a person will lose weight
daily energy intake is the total amount of energy consumed from foods and drinks. Estimated average requirements (EAR) for energy per day are recommended by the Scientific Advisory Committee on Nutrition (2011) as 10.9 MJ per day (2605 kcals per day) for adult men and 8.7 MJ per day (2079 kcals per day) for adult women. Daily EAR for children varies by age and gender
sugars added to foods by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit concentrates
for adults, a healthy weight is a BMI between 18.5 kg/m2 to 24.9 kg/m2. A healthy weight for children is dependent on their age and height (see 'Children who are overweight or obese')
joint strategic needs assessments (JSNAs) identify the current and future health needs of a local population. They are used as the basis for the priorities and targets set
moderate-to-vigorous physical activity needs a large amount of effort, causes rapid breathing and a substantial increase in heart rate. Examples include: jogging; energetic dancing; heavy gardening; playing badminton, tennis or football; fast cycling; or walking briskly up a hill
monitoring involves routine collection, analysis and reporting of a set of data to assess the performance of a weight management programme according to the service specification and intended health outcomes
measures the weight and height of children in reception class (aged 4 to 5) and Year 6 (aged 10 to 11). The aim is to assess the prevalence of obesity and overweight among children of primary school age, by local authority area. These data can be used at a national level to support local public health initiatives and inform local services for children
non-nutritive sweeteners give food and drinks a sweet taste but include no (or virtually no) energy and no other nutrients. Non-nutritive sweeteners are sometimes called low calorie, artificial or non-caloric sweeteners
the full range of human movement, from active hobbies, walking, cycling and the other physical activities involved in daily living, such as walking up stairs, gardening and housework to competitive sport and exercise
the Guideline Development Group considered that recent-onset type 2 diabetes would include those people whose diagnosis has been made within a 10-year time frame
definitions of wholegrain vary but include whole wheat, whole wheat flour, wheat flakes, bulgur wheat, whole and rolled oats, oatmeal, oat flakes, brown rice, whole rye and rye flour and whole barley

Paths in this pathway

Pathway created: October 2013 Last updated: April 2016

© NICE 2016

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