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Lifestyle weight management services for overweight or obese children and young people

About

What is covered

This NICE Pathway makes recommendations on lifestyle weight management (sometimes called tier 2) services for overweight and obese children and young people aged under 18. These services are just one part of a comprehensive approach to preventing and treating obesity.
The recommendations are for commissioners in local authorities and the NHS and providers of community-based services that take a 'lifestyle' approach to helping overweight or obese children and young people manage their weight. They are also for health professionals and people working with children and young people as well as members of the public.

Updates

Updates to this NICE Pathway

22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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 NICE 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 NICE 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 NICE 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

Everything NICE has said on lifestyle weight management services for overweight or obese children and young people in an interactive flowchart

What is covered

This NICE Pathway makes recommendations on lifestyle weight management (sometimes called tier 2) services for overweight and obese children and young people aged under 18. These services are just one part of a comprehensive approach to preventing and treating obesity.
The recommendations are for commissioners in local authorities and the NHS and providers of community-based services that take a 'lifestyle' approach to helping overweight or obese children and young people manage their weight. They are also for health professionals and people working with children and young people as well as members of the public.

Updates

Updates to this NICE Pathway

22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Obesity: clinical assessment and management (2016) NICE quality standard 127

Quality standards

Quality statements

Vending machines

This quality statement is taken from the obesity in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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.

Informing people of their BMI

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

People are informed of their BMI when it is calculated and advised about any associated health risks.

Rationale

The increasing prevalence of overweight and obesity can make it harder for people to recognise that they or their children are (or are at risk of becoming) overweight or obese. It is therefore important that people who are identified as being overweight or obese are informed of their BMI and understand what it means, any associated risks to their health and how they can get help. Calculation of BMI is often done as part of registration with a GP, or at hospital or community outpatient appointments for related conditions such as type 2 diabetes, cardiovascular disease or osteoarthritis. BMI measurement can also take place when people are admitted to hospital as inpatients, when they are having preoperative assessments and at booking appointments during pregnancy.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people are informed of their BMI when it is calculated.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people have a discussion with the healthcare professional about the associated health risks related to their BMI measurement.
Data source: Local data collection.
Process
a) Proportion of people who are informed of their BMI when it is calculated.
Numerator – the number in the denominator who are informed of their BMI.
Denominator – the number of people who have had their BMI calculated.
Data source: Local data collection.
b) Proportion of people who have a discussion with their healthcare professional about their associated health risks in relation to their BMI.
Numerator – the number in the denominator who had a discussion with their healthcare professional about their associated health risks in relation to their BMI.
Denominator – the number of people informed of their BMI.
Data source: Local data collection.
Outcome
a) Patient awareness of their BMI measurement.
Data source: Local data collection.
b) Patient understanding of the health risks associated with their weight.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary and secondary care providers) ensure that healthcare professionals are able to accurately measure and record height and weight, and are able to determine BMI centile using age- and gender-specific charts for children and young people. Service providers should also ensure that healthcare professionals inform people of their BMI when it is calculated, are able to assess the health risks associated with BMI or BMI centile scores, and are able to discuss health risks with people (and their families or carers, as appropriate) who have a BMI that shows they are overweight or obese, or who have health risks because of their weight.
Healthcare professionals (such as GPs, nurses, hospital clinicians and consultants) ensure that they inform people of their BMI when they calculate it, assess the health risks associated with the person’s BMI or BMI centile score, and ensure that there is time during the consultation to answer questions.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which healthcare professionals inform people of their BMI when they calculate it, assess the health risks associated with BMI or BMI centile scores, and discuss these risks with people who have a BMI that identifies that they are overweight or obese, or at health risk because of their weight.
People who have their body mass index (a measure of height and weight, often shortened to BMI) measured and who may be at risk of health problems because of their weight are told what their BMI is and have a discussion with a healthcare professional about what this might mean for their health. Their family members or carers can be involved in this discussion.

Source guidance

Definitions of terms used in this quality statement

BMI or BMI centile
BMI is calculated by dividing weight (in kilograms) by the square of height (in metres).
BMI measurement in children and young people should be related to the UK 1990 BMI charts to give age- and gender-specific information. BMI centiles can be identified using the Royal College of Paediatrics and Child Health’s UK-WHO growth charts. [Adapted from NICE’s guideline on obesity: identification, assessment and management, recommendation 1.2.12]
Associated health risks
Guidance on defining the degree of overweight or obesity and assessing associated health risks can be found in section 1.2 of the NICE guideline on obesity: identification, assessment and management.
Local voluntary organisations and support groups can also provide details on the health risks associated with being overweight or obese and help with approaches to weight loss. Discussions about likely resulting health problems can also therefore include providing details of such groups and how to contact them. [NICE’s guideline on obesity: identification, assessment and management, recommendation 1.4.8]
Once people are informed of their BMI they can be made aware of local lifestyle weight management programmes, in line with statement 6 in NICE’s quality standard on obesity in adults: prevention and lifestyle weight management programmes and statement 5 in NICE’s quality standard on obesity in children and young people: prevention and lifestyle weight management programmes.

Equality and diversity considerations

Some population groups, such as people of Asian family origin and older people, have comorbidity risk factors that are of concern at different BMIs. Clinical judgement should be used when considering risk factors in these groups.
There are circumstances when it may not be appropriate to inform someone of their BMI measurement, such as inpatients approaching the end of life.

Discussion on the choice of interventions

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

Adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful have a discussion about the choice of alternative interventions for weight management, including tier 3 services.

Rationale

People who have not benefited from tier 2 interventions should have a discussion with their healthcare professional about the options available. This can include tier 3 services, or equivalent, which provide specialist multidisciplinary team assessment and interventions. The choice of intervention should be agreed with the individual.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful have a discussion about the choice of alternative interventions for weight management, including tier 3 services.
Data source: Local data collection.
Process
Proportion of adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful who have a discussion about the choice of alternative interventions for weight management, including tier 3 services.
Numerator – the number in the denominator who have a discussion about the choice of alternative interventions for weight management, including tier 3 services.
Denominator – the number of adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful.
Data source: Local data collection.
Outcome
Patient satisfaction with knowing the full range of choices on offer.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary, community and secondary care) ensure that they have a choice of interventions available for people for whom tier 2 services have been unsuccessful. This includes agreed pathways for referral to tier 3 services, or equivalent, and awareness among healthcare professionals of the criteria for referral to these services and how to make a referral if the person agrees.
Healthcare professionals ensure that they have a discussion with adults who have a BMI of 30 or more for whom tier 2 interventions have been unsuccessful about their choice of alternative interventions for weight management, including tier 3 services. Healthcare professionals ensure that they emphasise to the person that this should not be seen as a failure on their part, but that it represents another treatment option that may be appropriate for them.
Commissioners (clinical commissioning groups) ensure that they commission locally available tier 3 services, or equivalent, and that there are agreed pathways for referral to these services.
Adults whose body mass index (a measure of height and weight, often shortened to BMI) is 30 or more have a discussion with their healthcare professional about the choice of other services for weight loss that are available, such as a weight-loss clinic, if they have not been able to lose weight through dieting or weight-loss programmes.

Source guidance

Definitions of terms used in this quality statement

BMI
BMI is calculated by dividing weight (in kilograms) by the square of height (in metres). [Adapted from NICE's guideline on obesity: identification, assessment and management, recommendation 1.2.12]
Tier 2 services
Although local definitions vary, lifestyle weight management programmes are usually called tier 2 services.
Lifestyle weight management programmes for overweight or obese people are multicomponent programmes that aim to reduce a person's energy intake and help them to be more physically active by changing their behaviour. They may include weight management programmes, courses or clubs that:
  • accept people 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.
Tier 3 service
If tier 3 services are not currently commissioned or available, support and assessment can be provided by equivalent services until tier 3 services become available. For example, medical assessment can be done in a tier 4 service if properly configured with a full multidisciplinary team that includes a doctor. [Adapted from NICE’s guideline on obesity: identification, assessment and management]
Unsuccessful interventions
Elements of such interventions may include:
  • previous attempts to lose weight
  • long history of cyclical weight loss and regain
  • person not ready to participate in a weight management programme
  • interventions that were not appropriate to the person’s needs.

Equality and diversity considerations

Some population groups, such as people of Asian family origin, have comorbidity risk factors that are of concern at different BMIs. Clinical judgement is needed when considering whether to refer to tier 3 services at lower BMI values.
People with learning disabilities may have different cognitive and social needs from the general population. Tier 3 services should be made accessible to address these needs.

Referring children and young people for specialist care

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

Children and young people who are overweight or obese and have significant comorbidities or complex needs are referred to a paediatrician with a special interest in obesity.

Rationale

Children and young people aged under 18 who are overweight or obese are at high risk of significant comorbidities. A paediatrician or GP is likely to identify those comorbidities during an initial assessment and can refer to a paediatrician with a special interest in obesity for investigations and access to tier 3 services.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that children and young people who are overweight or obese and have significant comorbidities or complex needs are referred to a paediatrician with a special interest in obesity.
Data source: Local data collection.
Process
a) Proportion of children and young people who are overweight or obese and have significant comorbidities who are referred to a paediatrician with a special interest in obesity.
Numerator – the number in the denominator who are referred to a paediatrician with a special interest in obesity.
Denominator – the number of children and young people who are overweight or obese and have significant comorbidities.
Data source: Local data collection.
b) Proportion of children and young people who are overweight or obese and have complex needs who are referred to a paediatrician with a special interest in obesity.
Numerator – the number in the denominator who are referred to a paediatrician with a special interest in obesity.
Denominator – the number of children and young people who are overweight or obese and have complex needs.
Data source: Local data collection.
Outcome
a) Access to tier 3 services for children and young people who are overweight or obese and have significant comorbidities or complex needs.
Data source: Local data collection.
b) Weight loss in children and young people who are overweight or obese and have significant comorbidities or complex needs.
Data source: Local data collection.
c) Exclusion of underlying medical causes of obesity in children and young people who are overweight or obese.
Data source: Local data collection.
d) Treatment of comorbidity in children and young people who are overweight or obese.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary care, community care and paediatric services) ensure that children and young people who are overweight or obese and have significant comorbidities or complex needs and have been referred to the service have access to a paediatrician with a special interest in obesity.
Healthcare professionals (such as GPs and paediatricians) ensure that they refer children and young people who are overweight or obese and have significant comorbidities or complex needs to a paediatrician with a special interest in obesity.
Commissioners (clinical commissioning groups) ensure that they commission locally available services that have access to a paediatrician with a special interest in obesity for children and young people who are overweight or obese and have significant comorbidities or complex needs.
Children and young people who are overweight or obese and have another medical condition or a special need such as a learning disability are offered referral to a paediatrician with a special interest in obesity.

Source guidance

Definitions of terms used in this quality statement

BMI centile
BMI measurement in children and young people should be related to the UK 1990 BMI charts to give age- and gender-specific information. BMI centiles can be identified using the Royal College of Paediatrics and Child Health’s UK-WHO growth charts. [Adapted from NICE’s guideline on obesity: identification, assessment and management, recommendation 1.2.12]
Significant comorbidities
These include benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, hyperinsulinaemia, type 2 diabetes, dyslipidaemia, orthopaedic problems and psychological morbidity. Obesity may result from an underlying condition such as an endocrine disease or condition or may be associated with various syndromes such as Prader-Willi syndrome. [NICE’s guideline on weight management: lifestyle services for overweight or obese children and young people, glossary definition of ‘complex obesity’ and expert opinion]
Complex needs
These include learning disabilities, chronic illness, physical disability and other additional needs. [NICE’s guideline on obesity: identification, assessment and management, recommendation 1.3.10 and expert opinion]

Referring adults with type 2 diabetes for bariatric surgery assessment

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

Adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes within the past 10 years are offered an expedited referral for bariatric surgery assessment.

Rationale

Bariatric surgery can improve quality of life and reduce the risk of premature mortality for people with obesity and type 2 diabetes of less than 10 years’ duration by improving glycaemic control and reducing or delaying the need for medication to control diabetes. An expedited referral means that people do not need to have tried non-surgical measures before they are referred for bariatric surgery assessment. Expedited referrals can be made by tier 3 services or equivalent if tier 3 services are not available locally.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes within the past 10 years are offered an expedited referral for bariatric surgery assessment.
Data source: Local data collection.
Process
Proportion of adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes within the past 10 years who have an expedited referral for bariatric surgery assessment.
Numerator – the number in the denominator who have an expedited referral for bariatric surgery assessment.
Denominator – the number of adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes within the past 10 years.
Data source: Local data collection.
Outcome
Bariatric surgery assessments for adults with a BMI of 35 or more diagnosed with type 2 diabetes within the past 10 years.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary and secondary care providers) ensure that adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes in the past 10 years are offered an expedited referral for bariatric surgery assessment.
Healthcare professionals (such as GPs, diabetologists and endocrinologists) ensure that they offer adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes in the past 10 years an expedited referral for bariatric surgery assessment. Healthcare professionals should discuss the benefits and risks of both bariatric surgery and non-surgical treatment when offering referral for assessment.
Commissioners (clinical commissioning groups) ensure that they commission services that can provide an expedited referral for bariatric surgery assessment and that pathways are in place locally to ensure that adults with a BMI of 35 or more who have been diagnosed with type 2 diabetes in the past 10 years are referred to these services. If tier 3 services are not currently commissioned or available, commissioners should ensure that people can be supported and referred by equivalent services until tier 3 services are available.
Adults who were diagnosed with type 2 diabetes within the past 10 years and whose body mass index (a measure of height and weight, often shortened to BMI) is 35 or more are offered a referral to find out if they could benefit from an operation to help them lose weight (called bariatric surgery).

Source guidance

Definitions of terms used in this quality statement

BMI
BMI is calculated by dividing weight (in kilograms) by the square of height (in metres). [Adapted from NICE’s guideline on obesity: identification, assessment and management, recommendation 1.2.12]
Expedited referral
The criterion that all appropriate non-surgical measures must have been tried before referral for bariatric surgery can be considered as a treatment option does not apply. [Adapted from NICE’s guideline on obesity: identification, assessment and management]

Equality and diversity considerations

People of Asian family origin have comorbidity risk factors that are of concern at BMIs different from those of the general population. Clinical judgement is needed when considering risk factors in these groups. Assessment for bariatric surgery for people of Asian family origin diagnosed with type 2 diabetes within the past 10 years should be considered at a lower BMI than other populations. [NICE’s guideline on obesity: identification, assessment and management, recommendation 1.11.3]
Surgical intervention is not generally recommended for children and young people. Bariatric surgery may be considered for young people only in exceptional circumstances and if they have reached or nearly reached physiological maturity. [NICE’s guideline on obesity: identification, assessment and management, recommendations 1.10.12 and 1.10.13]

Referring adults for bariatric surgery assessment

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

Adults with a BMI above 50 are offered a referral for bariatric surgery assessment.

Rationale

Bariatric surgery can improve quality of life and reduce the risk of premature mortality, and is the main option of choice for adults with a BMI above 50. There are additional criteria that need to be met before making a referral for bariatric surgery including, for example, whether a person has received (or will receive) appropriate intensive management and whether there is a commitment to long-term postoperative follow-up. Assessing all these criteria will identify people with a BMI above 50 who could benefit from bariatric surgery.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with a BMI above 50 are offered a referral for bariatric surgery assessment.
Data source: Local data collection.
Process
Proportion of adults with a BMI above 50 who are referred for bariatric surgery assessment.
Numerator – the number in the denominator who are referred for bariatric surgery assessment.
Denominator – the number of adults with a BMI above 50.
Data source: Local data collection.
Outcome
Bariatric surgery assessments for adults with a BMI above 50.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary, community-based and secondary care tier 3 services or equivalent) ensure that adults with a BMI above 50 are offered a referral for bariatric surgery assessment.
Healthcare professionals ensure that adults with a BMI above 50 are offered a referral for bariatric surgery assessment.
Commissioners (NHS England and clinical commissioning groups) ensure that services that they commission offer a referral for bariatric surgery assessment to adults with a BMI above 50.
Adults whose body mass index (a measure of height and weight, usually shortened to BMI) is more than 50 are offered a referral to find out if they could benefit from an operation to help them lose weight (called bariatric surgery).

Source guidance

Definitions of terms used in this quality statement

BMI
BMI is calculated by dividing weight (in kilograms) by the square of height (in metres). [Adapted from NICE’s guideline on obesity: identification, assessment and management, recommendation 1.2.12]
Referral for bariatric surgery assessment
The assessment aims to establish whether bariatric surgery is suitable for the person. Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:
  • All appropriate non-surgical measures have been tried but the person has not had or maintained adequate, clinically beneficial weight loss.
  • The person has been receiving or will receive intensive management in a tier 3 service.
  • The person is generally fit for anaesthesia and surgery.
  • The person commits to the need for long-term follow-up.

Equality and diversity considerations

People of Asian family origin have comorbidity risk factors that are of concern at BMIs different from those of the general population. Clinical judgement is needed when considering risk factors in these groups. Assessment for bariatric surgery for people of Asian family origin should be considered at a lower BMI than other populations. [NICE’s guideline on obesity: identification, assessment and management, recommendation 1.11.3]
Surgical intervention is not generally recommended for children and young people. Bariatric surgery may be considered for young people only in exceptional circumstances and if they have reached or nearly reached physiological maturity. [NICE’s guideline on obesity: identification, assessment and management, recommendations 1.10.12 and 1.10.13]

Follow-up care after bariatric surgery

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

People who have had bariatric surgery have a postoperative follow-up care package within the bariatric surgery service for a minimum of 2 years.

Rationale

The consequences of poor follow-up care after bariatric surgery can be severe and include weight regain, depression, nutritional deficiencies, osteoporosis, anaemia and death. Psychological screening and support after surgery, dietary advice and support, and specialist physical activity can ensure that the benefits of surgery are maximised.

Quality measures

Structure
Evidence of local arrangements to ensure that people who have had bariatric surgery are offered a follow-up care package within the bariatric service for a minimum of 2 years.
Data source: Local data collection.
Process
Proportion of people who have had bariatric surgery who have a follow-up care package within the bariatric service for a minimum of 2 years after bariatric surgery.
Numerator – the number in the denominator who have a postoperative follow-up care package within the bariatric service.
Denominator – the number of people who had bariatric surgery within the past 2 years.
Data source: Local data collection.
Outcome
a) Nutritional status in the first 2 years following bariatric surgery.
Data source: Local data collection.
b) Patient satisfaction with bariatric surgery.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary, community based, and secondary care tier 3 or tier 4 services) ensure that people who have had bariatric surgery are offered a follow-up care package within the bariatric service for a minimum of 2 years.
Healthcare professionals (bariatric surgery service staff) offer people who have had bariatric surgery follow-up care for at least 2 years after their operation.
Commissioners (clinical commissioning groups and NHS England) ensure that bariatric surgery services they commission offer a follow-up care package within the bariatric service for a minimum of 2 years after surgery. In addition, commissioners ensure that there are agreed local arrangements setting out which services will provide aspects of care (for example, a person’s GP may be involved in requesting blood tests or review appointments).
People who have had an operation to help them lose weight (called bariatric surgery) have follow-up care from the bariatric surgery service for at least 2 years after their operation. Follow-up care includes regular health check-ups, tests to make sure they are getting the nutrients they need, support with their diet, help to increase physical activity and psychological support if needed.

Source guidance

Definitions of terms used in this quality statement

Follow-up care package
This should be for a minimum of 2 years and include:
  • monitoring nutritional intake (including protein and vitamins) and mineral deficiencies
  • monitoring for comorbidities
  • medication review
  • dietary and nutritional assessment, advice and support
  • physical activity advice and support
  • psychological support tailored to the individual
  • information about professionally-led or peer-support groups.
For the first 2 years after surgery, follow-up appointments are likely to be with a dietitian or a bariatric physician. It is assumed that in the first year the person has 3 follow-up appointments, with annual follow-up thereafter. After the first 2 years, follow-up appointments are likely to be with either a dietitian or a GP within a locally agreed shared-care protocol. [ NICE’s full guideline on obesity: identification, assessment and management, section 8.1.3.2]

Nutritional monitoring after discharge from the bariatric surgery service

This quality statement is taken from the obesity: clinical assessment and management quality standard. The quality standard defines clinical best practice for obesity: clinical assessment and management and should be read in full.

Quality statement

People discharged from bariatric surgery service follow-up are offered monitoring of nutritional status at least once a year as part of a shared-care model of management.

Rationale

After bariatric surgery, unidentified nutritional deficiencies can occur and cause long-term harm (such as Wernicke’s encephalopathy, peripheral neuropathy, anaemia, osteoporosis or night blindness) or death. It is therefore important for people who have had bariatric surgery to have lifelong nutritional monitoring and appropriate nutritional supplementation, as part of a shared-care model of management. The management plan should involve collaboration between named tier 3 specialists and primary care as well as locally agreed monitoring arrangements and responsibilities.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people are offered at least annual monitoring of nutritional status and appropriate supplementation after discharge from bariatric surgery service follow-up as part of a shared-care model of management.
Data source: Local data collection.
b) Evidence of a locally agreed shared-care model of management for people who are discharged from bariatric surgery service follow-up, developed by tier 3 specialists and primary care.
Data source: Local data collection.
Process
Proportion of people discharged from bariatric surgery service follow-up who have at least annual monitoring of nutritional status and appropriate supplementation as part of a shared-care model of management.
Numerator – the number in the denominator who have had their nutritional status monitored within the past year as part of a shared-care model of management.
Denominator – the number of people discharged from bariatric surgery service follow-up more than 1 year ago.
Data source: Local data collection.
Outcome
Nutritional status after discharge from bariatric surgery service follow-up.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary, community-based, and secondary care services) ensure that people who are discharged from bariatric surgery service follow-up are offered monitoring of nutritional status at least once a year as part of a shared-care model of management.
Healthcare professionals (primary care and tier 3 service staff) ensure that they monitor the nutritional status of people discharged from bariatric surgery service follow-up at least once a year and prescribe appropriate supplementation if needed, as part of a shared-care model of management.
Commissioners (clinical commissioning groups and NHS England) ensure that local shared-care models of disease management are agreed between primary care and tier 3 services for people who are discharged from bariatric surgery service follow-up, and that a named person or unit responsible for recalling people and performing ongoing checks is clearly specified. This is part of a shared-care model of management.
People who had an operation to help them lose weight (called bariatric surgery) and have finished their follow-up care are offered a check-up at least once a year to make sure they are getting the nutrients they need. The check-up is part of a care plan that has been agreed between the person, their GP and other healthcare professionals involved in their care.

Source guidance

Definitions of terms used in this quality statement

Monitoring of nutritional status
This involves identifying any nutritional deficiencies, including vitamins, minerals and trace elements, after bariatric surgery and providing appropriate nutritional supplements. Clinicians should liaise with the local bariatric unit about patient-specific nutritional deficiencies and necessary treatment. [Adapted from NICE’s guideline on obesity: identification, assessment and management and expert opinion]
Shared-care model of management
A clear plan that outlines how a shared-care model of chronic disease management for lifelong annual follow-up after discharge from the bariatric surgery service will be implemented, including monitoring arrangements, common nutritional responsibilities and their treatment and responsibilities of the tier 3 specialist, the GP and the patient. The plan should involve collaboration between named tier 3 specialists and primary care. [Adapted from NICE’s guideline on obesity: identification, assessment and management]
Guidelines for the follow-up of patients undergoing bariatric surgery (O’Kane et al. 2016) provides further detail and potential models of shared-care protocols for postoperative management after bariatric surgery.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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 NICE 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 NICE 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 NICE 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

BMI z score

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). See the National Obesity Observatory's A simple guide to classifying body mass index in children.
Care is needed when interpreting BMI z scores using the UK 1990 centile charts for black, Asian and other minority ethnic groups. (These charts are used for children aged 4 years and older to determine whether their BMI is appropriate for their age and gender.)
There is evidence to suggest that adults from these groups are at risk of obesity-associated conditions and diseases at a lower BMI than the white population. See communicating with black, Asian and minority ethnic groups in the NICE Pathway on obesity: working with local communities. However, there are no growth reference charts for children from minority ethnic groups. (For more details on the differences in BMI thresholds as a trigger for disease among children in these groups see the National Obesity Observatory's report on Obesity and Ethnicity.)

Glossary

behaviour-change techniques are techniques aimed at changing the way someone acts (and so, logically, their thinking patterns). In this case, the changes relate to dietary intake and eating behaviour, physical activity and sedentary behaviour
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
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
comorbidities are diseases or conditions that someone has in addition to the health problem being studied or treated. Some comorbidities, such as type 2 diabetes, are associated with being overweight or obese, because the risk of developing them increases with an increasing BMI
evaluation involves assessing whether an intervention is meeting its objectives. This might include outcomes (for example, effectiveness in terms of BMI z score reduction or value for money). It might also include evaluation of processes (for example, how successful recruitment is or how acceptable the intervention is to participants)
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
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
in these recommendations, lifestyle weight management programmes refer to those that focus on diet, physical activity, behaviour-change or any combination of these elements
in these recommendations, lifestyle weight management programmes refer to those that focus on diet, physical activity, behaviour-change or any combination of these elements
(In these recommendations, 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.)
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
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
The National Child Measurement Programme (NCMP) 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
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
an obesity care or weight management pathway represents the various routes through local services that an individual child or young person might follow to help them manage their weight. A comprehensive obesity care or weight management pathway spans both prevention and treatment, offering services at different levels or 'tiers'. Children and young people may move between these services. In adult obesity care pathways, there may also be a further tier focusing on surgical treatment (sometimes called tier 4 services). Surgery is recommended for children and young people only in exceptional circumstances; see surgery in the NICE Pathway on obesity
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
positive parenting skills training is training for parents and carers that aims to improve children and young peoples' behaviour. It fosters effective boundary setting and the need to reward and praise children in a way that promotes positive relationships and self-esteem
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
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
rolling programmes are lifestyle weight management programmes that run on a continuous basis. Participants can start and end the programme at different points, covering the same material over the same number of weeks or months, but not necessarily in the same order. An advantage is that participants referred part way through a programme cycle do not have to wait for it to be completed and a new one to start before they join
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.
(In these recommendations, specialist obesity services – sometimes called tier 3 services – usually refers to clinical treatments provided by specialist services. This may include the use of drugs. These services could be for children or young people with severe or complex obesity, or with other special needs.)
(In these recommendations, specialist obesity services – sometimes called tier 3 services – usually refers to clinical treatments provided by specialist services. This may include the use of drugs. These services could be for children or young people with severe or complex obesity, or with other special needs.)

Paths in this pathway

Pathway created: March 2015 Last updated: October 2020

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