Transcript Implementing NICE Guidance

Obesity
Implementing NICE guidance
December 2006
NICE clinical guideline 43
What this presentation covers:
•
background
•
the guidance
•
key recommendations for prevention
•
•
key recommendations for assessment and
management
costs and savings
•
tools that can help
Background: changing practice
NICE guidance is based on the best available evidence.
The Department of Health asks NHS organisations to
work towards implementing NICE guidance, and
compliance will be monitored by the Healthcare
Commission.
Other organisations will want to use the guidance to
implement best practice.
Who the guidance is aimed at
•
local authorities and partners in the community
•
early years providers
•
schools
•
workplaces
•
self-help, commercial and community programmes
•
the public
•
the NHS
Need for this guidance
Rising prevalence of obesity in England
Over 50% of all adults are overweight or obese
Estimated current cost of obesity and overweight is
between £6.6 and £7.4 billion annually
Associated comorbidities
Children and
teenagers
Adults
• type 2 diabetes
• coronary heart
disease (CHD)
• hypertension
• various cancers
• osteoarthritis
•
•
•
•
•
hypertension
hyperinsulinaemia
dyslipidaemia
type 2 diabetes
psychosocial
dysfunction
• exacerbation of
existing conditions
• orthopaedic
problems
What the guidance covers
Prevention of overweight and obesity in adults and
children
Identification and assessment
Management of overweight and obesity in adults
and children:
•
•
•
lifestyle changes
drug treatment
surgery
Prevention and management of
obesity is a priority for all
Ensure that preventing and managing obesity is a
priority, at both strategic and delivery levels
Dedicate resources for action and training
Key recommendations
for local authorities
Work with local partners to create and manage more
safe spaces for incidental and planned physical
activity
Address as a priority any concerns around safety,
crime and inclusion
Provide facilities and schemes such as cycling and
walking routes, cycle parking, area maps and safe
play areas
Make streets cleaner and safer, through measures
such as traffic calming, congestion charging,
pedestrian crossings, cycle routes, lighting and
walking schemes
Recommended actions
for local authorities
All relevant workplace policies should support the local
obesity strategy
Work with the local community to identify environmental
barriers to eating healthily and being physically active
Ensure building designs encourage the use of stairs and
walkways
Encourage local shops and caterers to promote
healthy food and drink choices
Key recommendations
for early years settings
Minimise sedentary activities during play time
Provide regular opportunities for enjoyable
active play and structured physical activity sessions
Implement Department for Education and Skills, Food
Standards Agency and Caroline Walker Trust (see
www.cwt.org.uk) guidance on food procurement and
healthy catering
Involve parents and carers
Key recommendations
for schools
Head teachers and chairs of governors, in collaboration
with parents and pupils, should:
• assess the whole school environment
• ensure school policies help children to eat a
healthy diet, be physically active and maintain a
healthy weight
• use a whole-school approach to develop life-long
healthy eating and physical activity
practices
Recommended actions
for schools
Ensure school policies and the school’s environment
encourage physical activity and a healthy diet
Teaching, support and catering staff should have training
on how to implement healthy school policies
Establish links with health professionals
Key recommendation for
self-help, commercial and
community settings
Primary care organisations and local authorities
should recommend to patients, or consider
endorsing, self-help, commercial and community
weight management programmes only if they
follow best practice
Principles of best practice
Endorse programmes only if they meet best practice standards by:
•
helping people decide on a realistic healthy target weight
•
focusing on long-term lifestyle changes
•
addressing both diet and activity, and offering a variety of
approaches
•
using a balanced, healthy-eating approach
•
offering practical, safe advice about being more active
•
including some behaviour-change techniques
•
recommending and/or providing ongoing support
Key recommendations
for workplaces
Ensure policies encourage activity and healthy eating
Provide opportunities for staff to eat a healthy diet through
promotion of healthy choices in restaurants, hospitality,
vending machines and shops, in line with Food Standards
Agency guidance
Key recommendations
for workplaces
Provide opportunities for staff to be physically active
through:
• working practices and policies, such as active travel
policies for staff and visitors
• a supportive physical environment, such as
improvements to stairwells and providing showers and
secure cycle parking
• recreational opportunities, such as supporting out-ofhours social activities, lunchtime walks and use of
local leisure facilities
Key recommendations
for the NHS
Managers and health professionals in all primary care
settings should:
•
ensure that preventing and managing obesity is a
priority, at both strategic and delivery levels
•
dedicate resources for action and training
•
consider endorsing, self-help, commercial and
community weight management programmes
if they follow best practice
Recommended actions
for the NHS as an employer
Ensure policies encourage activity and healthy eating
among staff
Provide showers and secure cycle parking to encourage
active travel
Actively promote healthy choices in restaurants
Improve stairwells to encourage use of stairs
Recommended actions for all
health professionals
Offer tailored advice based on individual preferences
and needs
Involve parents and carers in actions aimed at
children and young adults
Discuss weight, diet and activity at times when weight
gain is more likely
Focus interventions on activities that fit easily into
everyday life
Use multicomponent interventions
Recommended actions for
health professionals in
community settings
Support and promote healthy eating and physical activity
through retail and catering schemes, schemes and
facilities to encourage physical activity, and behavioural
change programmes
Support implementation of workplace programmes on
obesity
In community programmes, address local concerns,
including the availability of services, cost and safety
Recommended actions for
health professionals in
early years settings
Use a range of components (not just parental education):
• offer interactive cookery and physical activity
demonstrations
• use videos and discussions on meal planning and
shopping
• provide opportunities for active play
Clinical recommendations
for the NHS
Identification and assessment
Management of overweight and obesity in adults
and children:
• lifestyle changes
• drug treatment
• surgery
Assessment and management:
adults
Determine degree of
overweight or obesity
Consider referral
to specialist care
Assess lifestyle,
comorbidities and
willingness to change
Management:
lifestyle changes;
drug treatment
Specialist assessment
and management;
surgery and follow up
Determine degree of
overweight or obesity: adults
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
25–29.9
Obesity I
30–34.9
Obesity II
35–39.9
Obesity III
40 or more
Use clinical judgement when interpreting BMI
Assess lifestyle, comorbidities and
willingness to change: adults
Including:
• presenting symptoms and underlying causes
of overweight or obesity
• willingness to change
• risk factors and comorbidities
• eating behaviour
• lifestyle – diet and physical activity
• psychosocial factors
Management: lifestyle changes
for adults
Offer multicomponent interventions, including
behaviour change strategies to encourage:
• increased physical activity
• improved eating behaviour
• healthy eating
Behavioural change
strategies: adults
• self monitoring of behaviour and progress
• stimulus control
• goal setting
• slowing rate of eating
• ensuring social support
Behavioural change
strategies: adults
• problem solving
• assertiveness
• cognitive restructuring (modifying thoughts)
• reinforcement of changes
• relapse prevention
• strategies for dealing with weight regain
Referral to specialist care:
adults
Consider referral to specialist care if:
• underlying causes of overweight and obesity need to be
assessed
• there are complex disease states and/or needs that cannot
be managed adequately in primary or secondary care
• conventional treatment has failed
• specialist interventions may be needed
• drug therapy is being considered for a person with a BMI of
50 kg/m2 or more
• surgery is being considered
Management: drug treatment
for adults
Drug treatment should be considered for adults:
• only after dietary and exercise advice have
been started and evaluated
• for patients who have not reached their
target weight or have reached a plateau
These recommendations update the NICE
technology appraisals on orlistat and sibutramine
Surgical treatment: adults
Consider surgery if all of the following conditions
are met:
• the person has a BMI of 40 kg/m² or more, OR
a BMI of 35 to 40 kg/m² plus other significant
disease that could be improved with weight loss
• non-surgical measures have failed to achieve or
maintain clinically beneficial weight loss for at
least 6 months
• the person has been receiving or will receive
intensive management in a specialist obesity
service, such as psychological support
Assessment and management:
children and young people
Determine degree of
overweight or obesity
Consider intervention
or assessment
Consider referral
to an appropriate
specialist
Assessment in
secondary care
Assess lifestyle,
comorbidities and
willingness to change
Management:
lifestyle changes
Specialist
management:
drug treatment;
surgery
Determine degree of overweight or
obesity: children and young people
• Use clinical judgement to decide when to
measure height and weight
• Use the
BMIUK
– UK
1990
1990
BMI
BMI
charts
charts
• Discuss with child/young person and their
family
Consider intervention or
tailored assessment: children
BMI
Consider:
91st centile
and above
Tailored intervention
98th centile
and above
Assessing for comorbidities
Assess lifestyle, comorbidities and
willingness to change: children
Including:
• presenting symptoms and underlying causes
of overweight or obesity,
• willingness to change
• risk factors and comorbidities
• eating behaviours
• lifestyle – diet and physical activity
• psychosocial factors
Management: lifestyle changes
for children
Offer multicomponent interventions that include
behaviour change strategies to:
• increase physical activity levels or decrease
inactivity
• improve eating behaviour or quality of diet
Behavioural change
strategies: children
•
•
•
•
•
stimulus control
self monitoring
goal setting
rewards for reaching goals
problem solving
Giving praise and encouraging parents to role-model
desired behaviours are also recommended
Referral to specialist care:
children
Consider referral to specialist care if the child has:
• significant comorbidity or
• complex needs – such as
learning or educational difficulties
Management:
drug treatment for children
Consider drug treatment only if multicomponent dietary,
exercise and behavioural approaches have been started
and evaluated.
Children under 12: drug treatment not generally recommended.
Prescribe only in exceptional circumstances such as severe
life-threatening comorbidities
Children over 12: drug treatment is recommended only if
there are severe comorbidities
Prescribing should be started by a specialist multidisciplinary
team with experience of prescribing for this age group
Surgical treatment:
young people
Surgery is not generally recommended
for children or young people.
However, in exceptional circumstances
it may be considered for young people.
Costs
Recommendations with a
significant resource impact
Annual costs
£000s
Recurrent costs
Treatment of overweight/obese
children with comorbidities
10,686
Bariatric surgery for obese adults
with BMI above 50 kg/m2
23,880
Non-recurrent costs
Appropriate training in obesity
management
28,756
TOTAL ESTIMATED COSTS
63,321
Savings
Recommendations with a
significant resource impact
Annual costs
£000s
Cash-releasing savings
Reduced prescription costs in
primary care
–13,992
Opportunity savings
Reduced GP contacts
–41,636
TOTAL ESTIMATED SAVINGS
–55,628
Access tools online
Costing tools
• costing report
• costing template
Guide to useful resources
Audit criteria
Available from: www.nice.org.uk/CG043
Access the guidance online
Two quick reference guides –
www.nice.org.uk/CG043quickrefguide
NICE guideline – all of the recommendations
www.nice.org.uk/CG043niceguideline
Full guideline – all of the evidence and rationale
www.nice.org.uk/CG043fullguideline
Two ‘Understanding NICE guidance’ booklets – plain
English versions www.nice.org.uk/CG043publicinfo