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Obesity

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What is covered

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

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
11 December 2017 Naltrexone–bupropion for managing overweight and obesity (NICE technology appraisal guidance 494) added to drug treatment.
27 June 2017 Title of paths on managing obesity in adults and in children and young people updated.
22 November 2016 Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy for treating morbid obesity (NICE interventional procedure guidance 569) added.
3 August 2016 Obesity: clinical assessment and management (NICE quality standard 127) added.
14 April 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
12 March 2015 Update on publication of preventing excess weight gain (NICE guideline NG7).
26 November 2014 Update on publication of obesity: identification, assessment and management (NICE guideline CG189).
26 November 2013 Implantation of a duodenal–jejunal bypass sleeve for managing obesity (NICE interventional procedure guidance 471) added.

Guiding principles

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

Community engagement

The prerequisites for effective community engagement are covered in NICE's guidance on community engagement.

Behaviour change

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

Cultural appropriateness

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

Principles of weight management for children and young people

Assessing the 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 interactive flowchart, 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 interactive flowchart, 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 interactive flowchart, 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.

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.

Short Text

Everything NICE has said on preventing, identifying, assessing and managing obesity in an interactive flowchart

What is covered

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

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
11 December 2017 Naltrexone–bupropion for managing overweight and obesity (NICE technology appraisal guidance 494) added to drug treatment.
27 June 2017 Title of paths on managing obesity in adults and in children and young people updated.
22 November 2016 Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy for treating morbid obesity (NICE interventional procedure guidance 569) added.
3 August 2016 Obesity: clinical assessment and management (NICE quality standard 127) added.
14 April 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
12 March 2015 Update on publication of preventing excess weight gain (NICE guideline NG7).
26 November 2014 Update on publication of obesity: identification, assessment and management (NICE guideline CG189).
26 November 2013 Implantation of a duodenal–jejunal bypass sleeve for managing obesity (NICE interventional procedure guidance 471) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Preventing excess weight gain (2015) NICE guideline NG7
Obesity prevention (2006 updated 2015) NICE guideline CG43
Naltrexone–bupropion for managing overweight and obesity (2017) NICE technology appraisal guidance 494
Implantation of a duodenal–jejunal bypass sleeve for managing obesity (2013) NICE interventional procedures guidance 471
Laparoscopic gastric plication for the treatment of severe obesity (2012) NICE interventional procedures guidance 432
Obesity: clinical assessment and management (2016) NICE quality standard 127
AccuVein AV400 for vein visualisation (2014) NICE medtech innovation briefing 6

Quality standards

Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups

These quality statements are taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statements

Designing health and wellbeing programmes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups have their views represented in setting priorities and designing local health and wellbeing programmes.

Rationale

Health and wellbeing programmes can support positive behaviour changes and contribute to promoting health and preventing premature mortality. People from black, Asian and other minority ethnic groups may not engage with services or may have a poor experience of those programmes and associated services if they are not culturally sensitive and appropriate. Involving people, community organisations and faith leaders who can represent the views of local minority ethnic groups helps to ensure that the services reflect the needs and preferences of the local population.

Quality measures

Structure
a) Evidence of work carried out to gather intelligence about the ethnic diversity of the local population.
Data source: Local data collection, for example, intelligence gathered for the Joint Strategic Needs Assessment.
b) Evidence of work carried out to gain understanding of the needs of black, Asian and other minority ethnic groups living in the local area.
Data source: Local data collection, for example, intelligence gathered for the joint strategic needs assessment.
c) Evidence of actions taken to gather views of local people from black, Asian and other minority ethnic groups on priorities for and design of health and wellbeing programmes.
Data source: Local data collection, for example, from programme planning, records from meetings (agendas or minutes) and focus groups.
d) Evidence of how intelligence on ethnic diversity, the needs and views of the local population is used to inform commissioning.
Data source: Local data collection, for example, information included in local health equality assessments.
Process
a) Proportion of local health and wellbeing programmes that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Numerator – the number in the denominator that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Denominator – the number of health and wellbeing programmes commissioned locally.
Data source: Local data collection, for example, service annual report.
b) Proportion of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes who felt that their views were valued.
Numerator – the number in the denominator that felt their views were valued.
Denominator – the number of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes.
Data source: Local data collection, for example, surveys carried out with people representing ethnic groups.
Outcome
a) Uptake of local health and wellbeing services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, service workflow.
b) Proportion of people from black, Asian and other minority ethnic groups referred to local health and wellbeing services who feel that the services meet their needs.
Data source: Local data collection, for example, service user survey.
c) Prevalence of obesity among local people from black, Asian and other minority ethnic groups.
Data source: NHS Digital’s Health Survey for England and National Child Measurement Programme, and local data collection, for example, GP practice data.
d) Physical activity levels among local people from black, Asian and other minority ethnic groups.
Data source: Active Lives, Sport England and local data collection, for example, review of service user records held by the provider.
e) Prevalence of tobacco use among local people from black, Asian and other minority ethnic groups.
Data source: Office for National Statistics’ Annual Population Survey and local data collection, for example, stop smoking service data.
f) Mental wellbeing among local people from black, Asian and other minority ethnic groups.
Data source: Local health data collection, for example mental health and wellbeing joint strategic needs assessment profile.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that the services they provide recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups. They continually review the services to ensure that they are culturally appropriate, accessible and tailored to the diverse needs of the local population.
Health, public health and social care practitioners recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups that they support. They ensure that the services they provide are culturally appropriate and accessible. This may mean working in partnership with existing local community groups or faith leaders who can support delivering some of the programmes in non-traditional community-based settings.
Commissioners (Public Health England, NHS England, local authorities, clinical commissioning groups) gather intelligence and gain understanding of the diversity of the local population and its needs. They ensure that the views of people from minority ethnic groups are represented when priorities are set and local health and wellbeing programmes are designed. This may be through engaging local communities using public consultation or community workshops that discuss future services. These can ensure that the local population is represented by individuals as well as established community groups and educational or religious leaders. The commissioners also ensure that local services have the skills mix and capacity to provide support that is culturally appropriate and tailored to the needs of people from black, Asian and other minority ethnic groups to make positive behaviour changes.
People from black, Asian and other minority ethnic groups advise on what local health and wellbeing programmes should focus on and what culturally sensitive and acceptable services should look like. They share their views during workshops or consultations organised by the commissioners, or through other people who they trust, such as community leaders or faith leaders.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. Commissioners and providers seeking to obtain the views and understand the needs of people from black, Asian and other minority ethnic groups should work closely with existing community groups, faith leaders and educators who may already have links to groups and individuals with poor access to services.

Peer and lay roles

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups are represented in peer and lay roles within local health and wellbeing programmes.

Rationale

People from black, Asian and other minority ethnic groups are underrepresented in health and wellbeing programmes. To ensure that the programmes are accessed and used by minority ethnic groups, commissioners and providers need to recognise the knowledge, skills and expertise of local communities. People known to and trusted by communities can take on peer and lay roles and encourage uptake of services among groups that may otherwise be reluctant to get involved. They can raise awareness, deliver information and advice in a culturally appropriate manner, and help with designing and providing interventions and services that are relevant, acceptable and tailored to the local population.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups are represented in peer and lay roles for local health and wellbeing programmes.
Data source: Local data collection, for example, from service planning and service design records, and recruitment records.
b) Evidence of local arrangements to support people from black, Asian and other minority ethnic groups taking on peer and lay roles in local health and wellbeing programmes.
Data source: Local data collection, for example, records of meetings, mentoring sessions, existing support networks or workshops with people taking on peer and lay roles.
Process
Proportion of local health and wellbeing programmes with people working in peer and lay roles who are representative of the local community.
Numerator – the number in the denominator with people working in peer and lay roles who are representative of the local community.
Denominator – the number of local health and wellbeing programmes.
Data source: Local data collection, for example, from service annual reports.
Outcome
a) The number of people from black, Asian and other minority groups who access local health and wellbeing programmes.
Data source: Local data collection, for example, review of service records.
b) The number of people in peer and lay roles supporting black, Asian and other minority ethnic groups to improve their health and wellbeing.
Data source: Local data collection, for example, review of service records.
c) Experience of engaging with local health and wellbeing programmes among people from black, Asian and other minority groups.
Data source: Local data collection, for example, service user survey.
d) Long-term retention of people in peer and lay roles.
Data source: Local data collection, for example, service annual report.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that they work with established community groups and educational or religious leaders to identify and recruit members of the local community who can support people from black, Asian and other minority ethnic groups and represent the diverse needs of the local population. They ensure that people in lay roles are supported with resources, information and mechanisms to proactively engage members of the community who may be excluded or disengaged. Service providers also support people in peer and lay roles with feedback, support networks, training and mentoring to allow them to fulfil their responsibilities, reach their full potential and continue with the role.
Commissioners (community and voluntary sector organisations and statutory services) understand the diversity of their local community and make a long-term commitment to funding and supporting effective community engagement approaches, such as peer and lay roles. They secure resources to recruit people to peer and lay roles and provide them with ongoing training and support.
People from black, Asian and other minority ethnic groups are given support and information by other members of their own community who are working closely with organisations that provide local health and wellbeing services. These people represent the interests and concerns of the community and ensure that local health and wellbeing programmes and services recognise the beliefs, expectations and values of people from black, Asian and other minority ethnic groups.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]
Peer and lay roles
Community members working in a non-professional capacity to support health and wellbeing initiatives. 'Lay' is the general term for a community member. 'Peer' describes a community member who shares similar life experiences to the community they are working with. Peer and lay roles may be paid or unpaid (that is, voluntary). Effective peer and lay approaches are:
  • Bridging roles to establish effective links between statutory, community and voluntary organisations and the local community and to determine which types of communication would most effectively help get people involved.
  • Carrying out 'peer interventions'. That is, training and supporting people to offer information and support to others, either from the same community or from similar backgrounds.
  • Community health champions who aim to reach marginalised or vulnerable groups and help them get involved.
  • Volunteer health roles whereby community members get involved in organising and delivering activities.
[NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. People in peer and lay roles may be more successful at engaging with and supporting people from similar backgrounds than traditional health and wellbeing services.

Referring people at high risk of type 2 diabetes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups at high risk of type 2 diabetes are referred to an intensive lifestyle change programme.

Rationale

People from certain ethnic communities have a higher risk of developing type 2 diabetes than those in the white European population. This includes people of South Asian, Chinese, black African and African-Caribbean family origin. In these populations, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level. Many cases of type 2 diabetes are preventable through changes to a person's diet and physical activity levels. Evidence-based intensive lifestyle change programmes can significantly reduce the risk of developing type 2 diabetes for those at high risk.

Quality measures

Structure
Evidence of local arrangements for identifying and referring people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes.
Data source: Local data collection, for example, GP contracts.
Process
a) Proportion of people from black, Asian and other minority ethnic groups identified as being at high risk of type 2 diabetes who are referred to an intensive lifestyle change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are identified as being at high risk of type 2 diabetes.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).
b) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who attended the programme.
Numerator – the number in the denominator who attended an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
c) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who completed the programme.
Numerator – the number in the denominator who completed an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
Outcome
a) Change in BMI among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
b) Change in blood pressure among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
c) Change in HbA1c among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
d) Prevalence of type 2 diabetes among people from black, Asian and other minority groups.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and Public Health England’s Diabetes prevalence estimates for local populations.

What the quality statement means for different audiences

Service providers (such as GPs and community healthcare providers) ensure that people from black, Asian and other minority ethnic groups who are identified as being at high risk of developing type 2 diabetes are referred to an intensive lifestyle change programme. They also ensure that systems are in place to start diabetes prevention interventions at a lower BMI threshold in people from minority ethnic groups at increased risk of type 2 diabetes. This may involve people in peer and lay roles raising awareness, assessing risks and providing advice on diabetes prevention among those ethnic minorities.
Health and public health practitioners (such as GPs, practice nurses and community healthcare providers) are aware that some black, Asian and other minority ethnic groups have an increased risk of type 2 diabetes. They refer people who are at high risk to an intensive lifestyle change programme and provide advice to those with a lower level of risk.
Commissioners (clinical commissioning groups, NHS England and local authorities in sustainability and transformation partnership areas) ensure that intensive lifestyle change programmes are available for people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes. They work with ethnic minorities to ensure that programmes include a range of culturally sensitive and appropriate behaviour change interventions.
People from black, Asian and other minority ethnic group at high risk of type 2 diabetes are referred to culturally sensitive and appropriate services that can help them achieve healthy weight and be more active. Those who are not currently at high risk of type 2 diabetes are given information and further support relevant to their needs.

Source guidance

Definitions of terms used in this quality statement

Intensive lifestyle change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
High risk of type 2 diabetes
High risk is defined as a fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%). These terms are used instead of specific numerical scores because risk assessment tools have different scoring systems. Examples of risk assessment tools include: Diabetes risk score assessment tool, QDiabetes risk calculator and Leicester practice risk score. Risk can also be assessed using the NHS Health Check.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
Lower thresholds (23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk) should be used for BMI to trigger action to prevent type 2 diabetes among Asian (South Asian and Chinese) populations compared to those used for the general population.

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may find it difficult to engage with services. Intensive lifestyle change programmes need to be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Cardiac rehabilitation

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are given a choice of times and settings for the sessions and are followed up if they do not attend.

Rationale

Cardiac rehabilitation programmes improve clinical outcomes for people who have had a cardiac event. However, uptake among people from black, Asian and other ethnic minority groups is lower than in the general population. Providing programmes that are culturally appropriate and sensitive, at settings and times that are convenient can increase uptake. Following up people who do not attend allows for a discussion about potential barriers to attendance and how to overcome them. It also gives the opportunity to motivate people to start or to continue with the programme.

Quality measures

Structure
a) Evidence of local arrangements to discuss any factors that might stop people from black, Asian or other minority ethnic groups from attending a cardiac rehabilitation programme, before they receive a referral.
Data source: Local data collection, for example, from service level agreements.
b) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups in a variety of settings including at home, in the community or in a hospital.
Data source: Local data collection, for example, from service level agreements.
c) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups at a choice of times, for example, sessions outside working hours.
Data source: Local data collection, for example, from service level agreements.
Process
a) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who are offered sessions in a variety of settings including home, the community or a hospital.
Numerator – the number in the denominator offered sessions in a variety of settings including home, the community or a hospital.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme.
Data source: Local data collection, for example, from patient records.
b) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme.
Data source: Local data collection, for example, from patient records.
c) Proportion of people from black, Asian and other minority ethnic groups who missed their cardiac rehabilitation appointment who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups participating in a cardiac rehabilitation programme who missed their appointment.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rate of uptake of cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
b) Rates of adherence to cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed cardiac rehabilitation programmes.
Data source: Local data collection, for example, surveys carried out with people referred to cardiac rehabilitation.

What the quality statement means for different audiences

Service providers (secondary and tertiary care services) ensure they provide individualised support for people from black, Asian and other minority ethnic groups to attend and continue with cardiac rehabilitation programmes. This may include working on overcoming barriers with people who are not willing to engage with services due to poor past experiences or ensuring that the programmes are run on different days, at different times and at venues that are culturally appropriate and convenient. Providers also ensure that a varied range of acceptable and culturally sensitive exercise is available, and people are followed up to continue with the programme.
Healthcare professionals (such as cardiologists and cardiac nurses) identify barriers to attending a cardiac rehabilitation programme and offer individualised support to people from black, Asian and other minority ethnic groups. They offer cardiac rehabilitation programmes on different days, at different times and venues (such as community centres or places of worship) and ensure that they are culturally appropriate and suitable. Healthcare professionals also follow-up people to motivate them to continue with the programme or understand the obstacles that may prevent people from using the service.
Commissioners (clinical commissioning groups) commission cardiac rehabilitation services that have the capacity and expertise to provide people from black, Asian and other minority ethnic groups with programmes that are suitable, acceptable and culturally appropriate. They also ensure that the services support people from black, Asian and other minority ethnic groups to attend and adhere to the programme by addressing the barriers to participation.
People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are supported to attend and keep going to the sessions. This might mean that sessions are available at venues and times convenient to the person or that the sessions are acceptable to them culturally, for example, single sex or with bilingual staff.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
A coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that people can, by their own efforts, continue to play a full part in their community and through improved health behaviour, slow or reverse progression of the disease. Cardiac rehabilitation should consist of a multidisciplinary, integrated approach delivering care in lifestyle risk factor management, psychosocial health, medical risk factor management and the optimal use of cardioprotective therapies, underpinned by psychologically informed methods of health behaviour change and education.
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components.
[NICE’s guideline on myocardial infarction, full guideline and recommendations 1.1.1 and 1.1.19]

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may find it difficult to engage with services. Also, some traditions and religious practices may stop people from accessing services on certain days or certain times of the day. Behaviour change programmes need to acknowledge those differences, be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Support for people with mental health problems

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups can access mental health services in a variety of community-based settings.

Rationale

People from black, Asian and other minority ethnic groups are less likely to access mental health treatment than the general population. Mental health illness can be associated with a considerable stigma among people from black, Asian and other minority ethnic groups. Some people may find community-based services, such as a person’s home or other residential settings, community centres and social centres, more appealing, accessible and culturally appropriate than traditional healthcare services. To help combat the stigma and encourage people with mental health problems to access support early, the services need to be visible, accessible and responsive to the needs of the local population.

Quality measures

Structure
a) Evidence of local arrangements to improve access to mental health services for people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, from local commissioning plans.
b) Evidence of local arrangements to ensure that mental health services are provided in a variety of settings that people from black, Asian and other minority ethnic groups can choose from.
Data source: Local data collection, for example, from service level agreements.
Process
Proportion of people from black, Asian and other minority ethnic groups accessing mental health services who are offered support in community-based settings.
Numerator – the number in the denominator offered support in community-based settings.
Denominator – the number of people from black, Asian and other minority ethnic groups accessing mental health services.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rates of uptake of mental health services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection for example, from GP records.
b) Proportion of people from black, Asian and other minority ethnic groups who complete treatment from mental health services.
Data source: Local data collection for example, from GP records.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed mental health services.
Data source: Local data collection, for example, surveys carried out with people referred to mental health services.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services, mental health services and independent providers) collaborate with local communities and people from black, Asian and other minority ethnic groups, healthcare professionals and commissioners to develop local care pathways that promote mental health services tailored to the needs of the local population. They ensure that services are provided in settings accessible and acceptable to people from black, Asian and other minority ethnic groups with mental health problems.
Healthcare professionals (such as GPs, psychiatrists, mental health nurses) offer people from black, Asian and other minority ethnic groups different options for where they can access mental health support to ensure they can choose acceptable and culturally appropriate services. They also collaborate with service providers, commissioners, communities and people from black, Asian and other minority ethnic groups to develop local care pathways that promote mental health services tailored to the needs of the local population.
Commissioners (such as clinical commissioning groups and local authorities) collaborate with local communities, people from black, Asian and other minority ethnic groups, healthcare professionals and service providers to develop local care pathways tailored to the needs of the local population. They ensure that mental health services are provided in a variety of settings and a range of support is available to facilitate access and uptake of services among people from black, Asian and other minority ethnic groups.
People from black, Asian and other minority ethnic groups are given a choice of places to access mental health support. Locations may include their own home, a community or social centre, a GP practice or other local health clinic.

Source guidance

Common mental health problems: identification and pathways to care (2011) NICE guideline CG123, recommendation 1.1.1.7

Definitions of terms used in this quality statement

Community-based settings
Community-based settings include the person's home or other residential settings, community centres and social centres.
[NICE’s guideline on common mental health problems, recommendation 1.1.1.7]

Equality and diversity considerations

Stigma attached to mental health problems among people from the black, Asian and other minority ethnic groups and fear of being sectioned or having children taken away by social services may stop people from accessing mental health support early. To ensure they are culturally appropriate and tailored to the diverse needs of the local population, members of the community should be involved in designing and reviewing the services as well as represented in peer and lay roles to ensure good links into the community.

Physical health checks for people with serious mental illness

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.

Rationale

Life expectancy for adults with a serious mental illness is significantly lower than for people in the general population. People from some black, Asian and other minority ethnic groups are at an increased risk of cardiovascular disease and type 2 diabetes and these conditions can be exacerbated by the use of antipsychotics. An annual health check helps to pick up on early signs of physical health conditions and enables action to be taken to prevent worsening health.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
b) Evidence of local primary and secondary care services working together to monitor and address the physical health needs of people affected by serious mental illness as part of the Rethink Mental Health Integrated Physical Health Pathway.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
Process
Proportion of people from black, Asian and other minority ethnic groups with a serious mental illness who have had a physical health assessment within the past 12 months.
Numerator – the number in the denominator who have had a physical health assessment within the past 12 months.
Denominator – the number of people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
Outcome
a) Premature mortality rates among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
b) Prevalence of type 2 diabetes among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).

What the quality statement means for different audiences

Service providers (such as GPs or mental health services) have systems in place to ensure that physical health assessments are carried out at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. The results are shared (under shared care arrangements) when the service user is in the care of both primary and secondary services. Service providers may involve people in peer and lay roles to support raising awareness of the increased risks and importance of physical health checks among people from black, Asian and other ethnic minority groups with a serious mental illness.
Healthcare professionals (such as GPs or nurses) carry out physical health assessments at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. They share the results (under shared care arrangements) when the service user is in the care of both primary and secondary services. They also highlight the increased risks and importance of physical health checks to people from black, Asian and other ethnic minority groups with a serious mental illness.
Commissioners (such as NHS England local area teams) ensure that they commission services that can demonstrate they are carrying out physical health assessments at least annually in people from black, Asian and other minority ethnic groups with a serious mental illness, and include this requirement in continuous training programmes. They also ensure that shared care arrangements are in place when the service user is in the care of both primary and secondary services, to ensure that the results of assessments are shared.
People from black, Asian and other minority ethnic groups with serious mental health problems have regular health checks (at least once a year). This is to check for problems that are common in people being treated for a serious mental illness, such as weight gain, diabetes, and heart, lung and breathing problems. The results are shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Serious mental illness
Schizophrenia, bipolar affective disorder and other psychoses.
Physical health assessment
A comprehensive health check focused on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. The annual check should include:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for people taking long-term lithium.
[Adapted from NICE’s guideline on bipolar disorder, recommendations 1.2.11 and 1.2.12]

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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189), 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.
[Obesity: identification, assessment and management (NICE guideline CG189), 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 obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) and statement 5 in obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94).

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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189), 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
NHS England and Public Health England's report Joined up clinical pathways for obesity and the Royal College of Surgeons’ report Weight assessment and management clinics (tier 3) provide details on the composition of tier 3 services and activities.
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 Obesity: identification, assessment and management (NICE guideline CG189)]
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.
[Adapted from Royal College of Surgeons’ report Weight assessment and management clinics (tier 3) and expert opinion]

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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189), 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.
[Management of obesity: a national clinical guideline (SIGN), section 19.2.3 and expert opinion]
Complex needs
These include learning disabilities, chronic illness, physical disability and other additional needs.
[Obesity: identification, assessment and management (2014) NICE guideline CG189, 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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189), 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 Obesity: identification, assessment and management (NICE guideline CG189)]

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.
[Obesity: identification, assessment and management (NICE guideline CG189), 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.
[Obesity: identification, assessment and management (NICE guideline CG189), 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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189), 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.
[Adapted from Obesity: identification, assessment and management (NICE guideline CG189), recommendation 1.10.1]

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.
[Obesity: identification, assessment and management (NICE guideline CG189), 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.
[Obesity: identification, assessment and management (NICE guideline CG189), 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 service providers, healthcare professionals and commissioners

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).

What the quality statement means for patients and carers

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.
[Obesity: identification, assessment and management (NICE guideline CG189), recommendation 1.12.1]
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.
[Obesity: identification, assessment and management (NICE full guideline CG189), 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 service providers, healthcare professionals and commissioners

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.

What the quality statement means for patients and carers

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 Obesity: identification, assessment and management (NICE guideline CG189) 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 Obesity: identification, assessment and management (NICE guideline CG189)]
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.

Vending machines

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for local authorities and NHS organisations

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Nutritional information at the point of choosing food and drink options

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for local authorities and NHS organisations

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Prominent placement of healthy options

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for local authorities and NHS organisations

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Maintaining details of local lifestyle weight management programmes

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Publishing performance data on local lifestyle weight management programmes

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Raising awareness of lifestyle weight management programmes

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Referral to a lifestyle weight management programme for people with comorbidities

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Preventing weight regain

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for adults

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Vending machines

This quality statement is taken from the obesity 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.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Guiding principles

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

Community engagement

The prerequisites for effective community engagement are covered in NICE's guidance on community engagement.

Behaviour change

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

Cultural appropriateness

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

Principles of weight management for children and young people

Assessing the 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 interactive flowchart, 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 interactive flowchart, 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 interactive flowchart, 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.

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.

Supporting information

The following recommendations are from NICE diagnostics guidance on depth of anaesthesia monitors.
The use of EEG-based depth of anaesthesia monitors is recommended as an option during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The BIS depth of anaesthesia monitor is therefore recommended as an option in these patients.
The use of EEG-based depth of anaesthesia monitors is also recommended as an option in all patients receiving total intravenous anaesthesia. The BIS monitor is therefore recommended as an option in these patients.
Although there is greater uncertainty of clinical benefit for the E-Entropy and Narcotrend-Compact M depth of anaesthesia monitors than for the BIS monitor, the Committee concluded that the E-Entropy and Narcotrend-Compact M monitors are broadly equivalent to BIS. These monitors are therefore recommended as options during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The E-Entropy and Narcotrend-Compact M monitors are also recommended as options in patients receiving total intravenous anaesthesia.
Anaesthetists using EEG-based depth of anaesthesia monitors should have appropriate training and experience with these monitors and understand the potential limitations of their use in clinical practice.
Make an initial assessment, then use clinical judgement to investigate comorbidities and other factors to an appropriate level of detail, depending on the person, the timing of the assessment, the degree of overweight or obesity, and the results of previous assessments.
Manage comorbidities when they are identified; do not wait until the person has lost weight.
Offer people who are not yet ready to change the chance to return for further consultations when they are ready to discuss their weight again and willing or able to make lifestyle changes. Give them information on the benefits of losing weight, healthy eating and increased physical activity.
Recognise that surprise, anger, denial or disbelief about their health situation may diminish people's ability or willingness to change. Stress that obesity is a clinical term with specific health implications, rather than a question of how people look; this may reduce any negative feelings.
During the consultation:
  • Assess the person's view of their weight and the diagnosis, and possible reasons for weight gain.
  • Explore eating patterns and physical activity levels.
  • Explore any beliefs about eating and physical activity and weight gain that are unhelpful if the person wants to lose weight.
  • Be aware that people from certain ethnic and socioeconomic backgrounds may be at greater risk of obesity, and may have different beliefs about what is a healthy weight and different attitudes towards weight management.
  • Find out what the person has already tried and how successful this has been, and what they learned from the experience.
  • Assess the person's readiness to adopt changes.
  • Assess the person's confidence in making changes.
Give people and their families and/or carers information on the reasons for tests, how the tests are done and their results and meaning. If necessary, offer another consultation to fully explore the options for treatment or discuss test results.
Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:
  • They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.
  • All appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss.
  • The person has been receiving or will receive intensive management in a tier 3 service. (For more information on tier 3 services, see NHS England's report on joined up clinical pathways for obesity.)
  • The person is generally fit for anaesthesia and surgery.
  • The person commits to the need for long-term follow-up.
The surgeon in the multidisciplinary team should:
  • have had a relevant supervised training programme
  • have specialist experience in bariatric surgery
  • submit data for a national clinical audit scheme. (The National Bariatric Surgery Registry is now available to conduct national audit for a number of agreed outcomes.)
Offer people who have had bariatric surgery a follow-up care package for a minimum of 2 years within the bariatric service. This should include:
  • nutritional monitoring, including screening for protein, vitamin 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.
After discharge from bariatric surgery service follow-up, ensure that all people are offered at least annual monitoring of nutritional status and appropriate supplementation according to need following bariatric surgery, as part of a shared care model of chronic disease management.
Extend the use of lower BMI thresholds to trigger action to prevent type 2 diabetes among black African and African-Caribbean populations.
Deliver any behavioural intervention with the support of an appropriately trained professional.
Do not use bioimpedance as a substitute for BMI as a measure of general adiposity.
Tailor dietary changes to food preferences and allow for a flexible and individual approach to reducing calorie intake.
Do not use unduly restrictive and nutritionally unbalanced diets, because they are ineffective in the long term and can be harmful.
Encourage people to improve their diet even if they do not lose weight, because there can be other health benefits.
Use clinical judgement to decide when to measure a person's height and weight. Opportunities include registration with a general practice, consultation for related conditions (such as type 2 diabetes and cardiovascular disease) and other routine health checks.
Multicomponent interventions are the treatment of choice. Ensure weight management programmes include behaviour change strategies to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet and reduce energy intake.
When choosing treatments, take into account:
  • the person's individual preference and social circumstance and the experience and outcome of previous treatments (including whether there were any barriers)
  • the person's level of risk, based on BMI and, where appropriate, waist circumference (see identifying people who are overweight or obese).
  • any comorbidities.
Document the results of any discussion. Keep a copy of the agreed goals and actions (ensure the person also does this), or put this in the person's notes.
Offer support depending on the person's needs, and be responsive to changes over time.
Ensure any healthcare professionals who deliver interventions for weight management have relevant competencies and have had specific training.
Provide information in formats and languages that are suited to the person. Use everyday, jargon-free language and explain any technical terms when talking to the person and their family or carers. Take into account the person's:
  • age and stage of life
  • gender
  • cultural needs and sensitivities
  • ethnicity
  • social and economic circumstances
  • specific communication needs (for example because of learning disabilities, physical disabilities or cognitive impairments due to neurological conditions).
Praise successes – however small – at every opportunity, to encourage the person through the difficult process of changing established behaviour.
Give people who are overweight or obese, and their families and/or carers, relevant information on:
  • being overweight and obesity in general, including related health risks
  • realistic targets for weight loss
  • the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; advise them that the change from losing weight to maintenance typically happens after 6–9 months of treatment
  • realistic targets for outcomes other than weight loss, such as increased physical activity and healthier eating
  • diagnosis and treatment options
  • healthy eating in general (more information on healthy eating can be found at NHS Choices)
  • medication and side effects
  • surgical treatments
  • self-care
  • voluntary organisations and support groups and how to contact them.
Ensure there is adequate time in the consultation to provide information and answer questions.
If a person (or their family or carers) do not feel this is the right time for them to take action, explain that advice and support will be available in the future whenever they need it. Provide contact details so that the person can get in touch when they are ready.
Offer regular, non-discriminatory long-term follow-up by a trained professional. Ensure continuity of care in the multidisciplinary team through good record-keeping.
The hospital specialist and/or bariatric surgeon should discuss the following with people who are severely obese if they are considering surgery to aid weight reduction:
  • the potential benefits
  • the longer-term implications of surgery
  • associated risks
  • complications
  • perioperative mortality.
The discussion should also include the person's family, as appropriate.
Choose the surgical intervention jointly with the person, taking into account:
  • the degree of obesity
  • comorbidities
  • the best available evidence on effectiveness and long-term effects
  • the facilities and equipment available
  • the experience of the surgeon who would perform the operation.
Provide regular, specialist postoperative dietetic monitoring, including:
  • information on the appropriate diet for the bariatric procedure
  • monitoring of the person's micronutrient status
  • information on patient support groups
  • individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance.
Arrange prospective audit so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term. (The National Bariatric Surgery Registry is now available to conduct national audit for a number of agreed outcomes.)
Pharmacological treatment may be used to maintain weight loss, rather than to continue to lose weight.
If there is concern about micronutrient intake adequacy, a supplement providing the reference nutrient intake for all vitamins and minerals should be considered, particularly for vulnerable groups such as older people (who may be at risk of malnutrition) and young people (who need vitamins and minerals for growth and development).
Offer support to help maintain weight loss to people whose drug treatment is being withdrawn; if they did not reach their target weight, their self-confidence and belief in their ability to make changes may be low.
Offer an expedited assessment for bariatric surgery to people with a BMI of 35 and over who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).
Consider an assessment for bariatric surgery for people with a BMI of 30–34.9 who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).

International guidance on waist circumference thresholds

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

European
Men
94 cm (37 inches)
Women
80 cm (31.5 inches)
South Asians
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Chinese
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Japanese
Men
90 cm (35 inches)
Women
80 cm (31.5 inches)
Ethnic south and central Americans
Use south Asian recommendations until more specific data are available
Sub-Saharan Africans
Use European data until more specific data are available
Eastern Mediterranean and middle east (Arab) populations
Use European data until more specific data are available
Other guidance is available from:
  • Scottish Intercollegiate Guidelines Network (2010)
  • Ministry of Health India (Misra et al. 2009)
  • Ministry of Health Singapore (Health Promotion Board Singapore 2005)
  • Obesity in Asia Collaboration (2007)
  • Cooperative meta-analysis group of the working group on obesity in China (Zhou 2002).

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

White European populations
Asian populations
Description
Less than 18.5 kg/m2
Less than 18.5 kg/m2
underweight
18.5–24.9 kg/m2
18.5–23 kg/m2
increasing but acceptable risk
25–29.9 kg/m2
23–27.5 kg/m2
increased risk
30 kg/m2 or higher
27.5 kg/m2 or higher
high risk
This includes the food and drink (including alcoholic drinks) consumed, energy and nutrient intake, portion size and the pattern and timing of eating.
When energy intake from all food and drink (measured as calories or kilojoules) matches energy used for all bodily functions and physical activity. If energy intake is higher than energy used, a person will gain weight. If energy intake is less than energy used, a person will lose weight.
Total energy content (kJ) divided by total weight (grams). Energy density can be calculated for individual foods, drink or for dietary intake as a whole. Lower energy dense foods, drinks or meals provide fewer calories per gram than higher energy dense foods, drinks or meals. High energy dense foods tend to be higher in fat or sugar and include crisps, nuts, confectionery, biscuits, cakes, full fat cheese and meat products. Low energy dense foods tend to be higher in water and lower in fat or sugar and include fruit and vegetables, soups and stews.
Daily energy intake is the total amount of energy consumed from foods and drinks. Estimated average requirements for energy per day are recommended by the Scientific Advisory Committee on Nutrition (2011) as 10.9 MJ per day (2605 kcals per day) for adult men and 8.7 MJ per day (2079 kcals per day) for adult women. Daily estimated average requirements for children varies by age and gender.
Sugars added to foods by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit concentrates.
For adults, a healthy weight is a BMI between 18.5 kg/m2 to 24.9 kg/m2. A healthy weight for children is dependent on their age and height.
Joint strategic needs assessments identify the current and future health needs of a local population. They are used as the basis for the priorities and targets set.
Moderate-to-vigorous physical activity needs a large amount of effort, causes rapid breathing and a substantial increase in heart rate. Examples include: jogging; energetic dancing; heavy gardening; playing badminton, tennis or football; fast cycling; or walking briskly up a hill.
Non-nutritive sweeteners give food and drinks a sweet taste but include no (or virtually no) energy and no other nutrients. Non-nutritive sweeteners are sometimes called low calorie, artificial or non-caloric sweeteners.
The full range of human movement, from active hobbies, walking, cycling and the other physical activities involved in daily living, such as walking up stairs, gardening and housework to competitive sport and exercise.
Definitions of wholegrain vary but include whole wheat, whole wheat flour, wheat flakes, bulgur wheat, whole and rolled oats, oatmeal, oat flakes, brown rice, whole rye and rye flour and whole barley.

Why we made these recommendations on naltrexone–bupropion

Obesity is very common in England, affecting about 30% of the population. Current management for overweight and obesity is lifestyle measures alone, lifestyle measures with orlistat or bariatric surgery.
Clinical trial evidence shows that naltrexone–bupropion with lifestyle measures is more effective than lifestyle measures alone, but its long-term effectiveness is unknown.
The estimate of cost effectiveness for naltrexone–bupropion with lifestyle measures, compared with lifestyle measures alone, is highly uncertain because of uncertainties in the modelling assumptions. Large numbers of people could be eligible for treatment which could potentially be long-term, leading to high overall costs for naltrexone–bupropion. Therefore, in these circumstances more certainty is needed that naltrexone–bupropion will provide value for the NHS.
For more information see the committee discussion in the NICE technology appraisal on naltrexone–bupropion for managing overweight and obesity.

Glossary

Bispectral Index
childhood and puberty close monitoring
electroencephalography
routine collection, analysis and reporting of a set of data to assess the performance of a weight management programme according to the service specification and intended health outcomes
measures the weight and height of children in reception class (aged 4 to 5) and Year 6 (aged 10 to 11). The aim is to assess the prevalence of obesity and overweight among children of primary school age, by local authority area. These data can be used at a national level to support local public health initiatives and inform local services for children
considered to include those people whose diagnosis has been made within a 10-year timeframe

Paths in this pathway

Pathway created: October 2013 Last updated: May 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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