Weight management: lifestyle services for overweight or obese children and young people

Directors of public health and public health teams working on obesity and child health and wellbeing.

Health and wellbeing boards.

Local authority commissioners.

Clinical commissioning groups.

NHS England.

Public Health England.

Children's services.

Ensure family-based, multi-component lifestyle weight management services for children and young people are available as part of a community-wide, multi-agency approach to promoting a healthy weight and preventing and managing obesity. These services should contain the core elements described in recommendation 3. They should be provided as part of a locally agreed obesity care or weight management pathway.

Dedicate long-term resources to support the development, implementation, delivery, promotion, monitoring and evaluation of these services. See recommendation 7 in NICE's guideline on obesity: working with local communities and principle 7 in NICE's guideline on behaviour change: general approaches.

Use data from the joint strategic needs assessment and the National Child Measurement Programme to identify local need. See recommendation 1 in NICE's guideline on obesity: working with local communities.

Directors of public health and public health teams working on obesity and child health and wellbeing.

Health and wellbeing boards.

Local authority commissioners.

Clinical commissioning groups.

NHS England.

Public Health England.

Children's services.

Identify needs using the joint strategic needs assessment. Use community engagement techniques with local families to identify any barriers and facilitators discouraging or encouraging the uptake and completion of programmes.

Commission lifestyle weight management services to meet the needs of local children and young people, including those of different ages, different stages of development and from different cultural backgrounds. Services should be in line with the health and wellbeing strategy.

Consider how best to provide services for overweight or obese children and young people with special needs or disabilities. For example, through specific programmes where these are available. Or by making reasonable adaptations to mainstream programmes (including training staff) and evaluating them. Ensure there is an appropriate interface with specialist obesity services to help those with more complex needs manage their weight.

Ensure all lifestyle weight management programmes are designed and developed with input from a multidisciplinary team and have taken into account the views of children, young people and their families. The team should include professionals who specialise in children, young people and weight management. These include the following:

Ensure programme content is regularly reviewed and updated by the multidisciplinary team.

Ensure providers can demonstrate that staff are trained to deliver the specific programme commissioned and are experienced in working with children, young people and their families.

Ensure sufficient resources are dedicated to monitoring and evaluation.

Ensure there are clearly defined programme objectives, outputs, outcomes and monitoring and evaluation requirements in programme specifications and in contracts. Contracts should also specify any at-risk groups that should be targeted, such as black and minority ethnic groups, or children and young people from low-income families or neighbourhoods.

Ensure key performance indicators are agreed with programme providers, including the proportion of sessions that must be attended to complete the programme (see recommendation 15).

Ensure the contract or programme specification requires that height and weight are measured and that both BMI and BMI for age and gender (BMI z score) are recorded. All children and young people should be measured at the following times:

Providers of lifestyle weight management programmes.

Ensure all lifestyle weight management programmes for overweight and obese children and young people are multi-component. They should focus on:

Ensure the following core components, developed with the input of a multidisciplinary team (see recommendation 2) are included:

Providers of lifestyle weight management programmes.

Assess each child or young person for obesity-associated diseases or conditions (comorbidities). Use a locally approved comorbidities assessment tool, where available. Assessment is particularly important if the child or young person and their family have self-referred to the programme, or have not been assessed by a health professional. Refer them to their GP if any concerns are identified.

Identify whether the child or young person's mental wellbeing is affected by their weight. For example, whether there are any signs of psychological distress, depression, bulimia, self-harming or other mental health problems related to their weight.

Identify whether their weight is a consequence of circumstances that have affected their mental wellbeing. (For example, if they have experienced bereavement or have caring responsibilities.)

If concerns about their mental wellbeing are identified refer the child or young person to their GP for assessment and treatment and, if appropriate, for onward referral to child and adolescent mental health services (CAMHS). (Note: such concerns may be identified at any stage of a weight management programme.)

Take account of the child or young person's self-esteem, self-perception and any previous attempts to manage their weight. Provide opportunities, in either a group or one-to-one session, for them to talk about any victimisation or distress if they wish. (This includes any history of bullying or teasing.)

Find out whether the family recognises that their child is overweight or obese and the potential benefits of managing their weight. Discuss the family's history of attempts to manage their weight, and their existing knowledge of, and attitudes towards, food, physical activity and the amount of time spent being sedentary.

Weigh, measure, determine and record the child or young person's BMI. Offer to do the same for parents, carers and other family members. Measurements should be undertaken by staff who have been trained using standard protocols (see recommendation 11).

They should use validated, transportable instruments that are regularly calibrated.

Emphasise that the programme may benefit the whole family. In addition, offer information about local lifestyle weight management services to adult family members who are overweight or obese.

Encourage children and young people from around the age of 12 (depending on their ability and stage of development) to monitor their eating, physical activity and any sedentary behaviour. For example, encourage them to keep a record of time spent watching television or playing computer games, and what they snack on and when, to identify areas that need addressing. For younger children, parents and carers should monitor these behaviours, with the involvement of the child according to their age and stage of development.

Work with children from around the age of 12 (depending on their ability and stage of development) to identify situations in which it would be possible for them to eat more healthily or to become less sedentary and more active. For example, this might involve gradually reducing TV viewing at certain times and replacing this with more active pastimes. Work with the parents and carers of younger children to achieve the same.

Aim to gradually increase the amount of moderate to vigorous-intensity physical activity programme participants do every day. Focus on activities they enjoy and that are easily accessible. This includes activities that can be built into daily life, such as active play, walking or cycling. Aim to achieve the age-specific UK physical activity guidelines.

Agree dietary changes that are age-appropriate, affordable, culturally sensitive and consistent with healthy eating advice. Ensure nutrient needs for growth and development are met by including healthier choices, in appropriate amounts, from each of the food groups (see NHS Eatwell plate). Changes to diet should take into account the child or young person's likes and dislikes.

Manage expectations of what can be realistically achieved over the duration of the programme. Small but realistic goals should be mutually agreed with the child or young person and their family. These should relate to goals that they value and that motivate them to attend.

Work with participants and their families to regularly monitor progress against the goals and provide feedback. Praise progress and achievements and update the goals as the child or young person progresses through the programme. If they do not meet their goals, discuss the possible causes for this and modify them if necessary.

Stress the importance of maintaining changes, no matter how small, over the longer term. Encourage participants to take up offers of ongoing support (see recommendation 10).

Providers of lifestyle weight management programmes.

Offer programmes to groups of children or young people and their families. Where necessary, offer programmes to individual families, if this better meets their needs and preferences. For example, some families may prefer to attend individual sessions initially and attend group sessions as their confidence and self-esteem grows.

Offer a range of programmes for children and young people of different ages and at different stages of development. If group sessions are offered, work with groups of peers and their parents or carers. Note, some adolescents may respond better to programmes if their sessions are separate from those for their parents and carers.

Offer programmes in venues that have the necessary facilities, are easily accessible and where the child or young person and their family feel comfortable. For example, use local community venues that have space for physical activities or games, and that can be reached quickly and easily by walking, cycling or using public transport.

Offer programmes at a range of times that are convenient for families with children of different ages and for working parents and carers. For example, some sessions could be offered in the evenings or at weekends.

Adopt a flexible approach so that participants can accommodate other commitments. They may also prefer to attend programmes more frequently initially and less frequently as their skills and confidence in making changes grows. For example, use rolling programmes that allow participants to start at different points and cover the same material but not necessarily in the same order.

Emphasise the importance of parental (or carer) support and their commitment to adhere to the programme. Stress that this support and commitment should extend beyond the duration of the programme itself and that outcomes will be reviewed for at least the first year after completion.

Maintain regular contact with participants. Promptly follow up those who miss sessions to establish why and to restore commitment. Focus on participants from disadvantaged groups and those who miss sessions early on in the programme.

Try to retain the same team of staff throughout each cycle of the programme.

Directors of public health and their teams.

Local authority commissioners.

NHS commissioners.

NHS and local authority communications teams.

Providers of lifestyle weight management programmes.

Local authorities should ensure an up-to-date list of local lifestyle weight management programmes for children and young people is maintained. This should form part of a list of services commissioned for the local obesity care or weight management pathway. It should be regularly disseminated, or accessible to organisations in the public, community and voluntary sectors.

Use children's centres, libraries, the local media, professional and voluntary organisations working with children and young people and schools to raise awareness of lifestyle weight management programmes. Any publicity should clearly describe:

Commissioners, public health teams and providers should raise awareness of the programmes among health professionals who may refer children and young people. This includes GPs and staff involved in the National Child Measurement Programme and the Healthy Child Programme. For example, the programme could be publicised through health professional networks and by offering training sessions on the programmes and how to make referrals.

Health professionals, in particular, GPs, dietitians, health visitors, school nurses and those involved in delivering the National Child Measurement Programme and the Healthy Child Programme.

Schools, colleges, early years organisations, children's centres and looked-after children's teams and other professionals who work with children and young people. For example, youth workers, social workers, and pastoral care workers.

Health professionals should tell the parents or carers of children and young people who have been identified as being overweight or obese about local lifestyle weight management programmes. They should explain what these involve and how they can take part (including whether or not they can self-refer).

Other professionals who work with children and young people should raise awareness of lifestyle weight management programmes for overweight and obese children and young people. They should also raise awareness of how to enrol on them.

Children's community nurses, dietetic teams, GPs, health visitors, primary care teams, obesity specialists, paediatricians, school nurses and school healthcare teams.

Where there are concerns about a child or young person's weight, weigh them in light clothing on clinically approved, regularly calibrated scales. In children older than 2 years, measure their height using a stadiometer. (See the National Obesity Observatory's standard evaluation framework for weight management interventions, for practical advice on weighing and measuring children).

Use the UK growth charts for children aged 4 years and older to determine BMI centile for their age and gender. Use the UK-WHO 0 to 4 years growth chart to determine if children younger than 4 are a healthy weight. Record this in the child or young person's health record.

Take account of their BMI centile, any obesity-associated diseases or conditions (comorbidities) they may have, or family medical history, and any psychosocial considerations, to determine whether referral to a lifestyle weight management programme is clinically appropriate.

Use tact and diplomacy to find out if the family and the child or young person accepts that the child or young person is overweight or obese. If they do accept this and it is clinically appropriate to refer them to a lifestyle weight management programme, explain the potential benefits they will gain – and the risks of not addressing their child's weight. In addition:

Assess whether the child or young person and their family are ready and willing to be referred. If they are ready, refer them to an effective lifestyle weight management programme (see recommendation 3).

If the family is not ready to attend a programme:

If children or young people need specialist support to manage their weight, refer them to specialist obesity services (if available) or to paediatric services.

If there are concerns about the child or young person's mental wellbeing related to their weight, use the local pathway to refer them to CAMHS. Ensure their GP is informed.

Children's community nurses, dietetic teams, GPs, health visitors, members of primary care teams, obesity specialists, paediatricians and school nurses and school healthcare teams.

Health professionals should use feedback from the programmes to help regularly monitor progress and provide ongoing support. They should acknowledge that:

After the programme has been completed, health professionals should continue to monitor the child or young person's BMI centile when the opportunity arises and at 6 months and 1 year after they complete the programme.

If the child or young person's BMI centile begins to increase, or if they or their parents or carers express concerns about their weight (or sustaining changes in their behaviour), discuss the possible causes. If necessary, consider another referral to the same or an alternative lifestyle weight management programme that may better address the needs of the family. Or consider referral to specialist obesity services (if available), or to a paediatrician.

Providers of lifestyle weight management programmes.

With the participants' consent, providers should send feedback to their referring GP or healthcare professional.

Offer all participants ongoing support when they have completed the programme. This support should be offered for at least the first year and longer, if possible, depending on the family's needs. Offer a range of options including follow-up sessions at different times and in easily accessible and acceptable venues.

Tell participants about local services and activities that may provide further support to help them manage their weight, for example, local leisure services and walking or cycling groups.

Providers of lifestyle weight management programmes.

Ensure staff are trained to deliver the weight management programme they will be working on. Ensure the training has been developed with the input of, and is regularly reviewed by, a multi-disciplinary team of professionals (see recommendation 2). Ensure staff training needs are regularly reviewed and addressed.

Ensure programme staff treat overweight and obese children, young people and their families with empathy, by making them aware of:

Train staff:

Providers of lifestyle weight management programmes.

Ensure staff have the necessary knowledge and skills to deliver multi-component programmes to children, young people and their families. This includes knowledge and skills in relation to: childhood obesity management, diet and physical activity. It may also include training in behaviour-change techniques and psychological approaches (for example, motivational interviewing).

Ensure there are staff available who can provide parenting skills training. Also ensure there are staff trained in practical food preparation.

Ensure staff are able to empathise and communicate effectively with the family. They should be able to work collaboratively with them and tailor interventions for individual needs. They should also be able to lead group work and set an appropriate pace when delivering the programme. In addition, they should be able to judge when changes in behaviour have become embedded, before introducing further changes.

Ensure staff can review progress and provide constructive feedback. They should be able to help children, young people and their families to identify possible reasons for relapse and use problem-solving techniques to address these.

Identify any gaps in staff knowledge or skills (or a lack of confidence). Address any gaps through training.

Employers.

Professional bodies responsible for setting competencies and designing continuous professional development programmes for health professionals.

Understand why some children and young people may have difficulty managing their weight and the experiences that they may face in relation to their weight.

Are aware of how obesity is viewed in different cultures and the issues they may need to consider to ensure any recommended activities are culturally acceptable. See NICE's guideline on promoting physical activity for children and young people.

Can accurately measure and record height and weight and determine BMI centile, using age- and gender-specific charts.

Can raise the issue of weight management confidently and sensitively. They should be able to help parents and carers identify when their child is overweight or obese and understand the benefits of addressing their weight.

Are familiar with the local obesity care or weight management pathway and any locally approved comorbidities assessment tools.

Can assess whether referral to a lifestyle weight management service is appropriate, or whether they should be referred to specialist obesity services or other specialist services (for example, paediatric services).

Can identify suitable lifestyle weight management programmes for children, young people and their families and can provide them with information and ongoing support (see recommendations 9 and 10).

Employers of staff working on, or referring children and young people to, lifestyle weight management programmes.

Providers of lifestyle weight management programmes.

If those involved in referring to, or delivering, lifestyle weight management programmes lack the confidence and skills to discuss weight management, offer them support and training.

If staff identify that the reason for their lack of confidence is a result of being overweight or obese themselves, offer them access to weight management programmes.

Directors of public health and public health teams working on obesity and child health and wellbeing.

Health and wellbeing boards.

Local authority commissioners.

Clinical commissioning groups.

NHS England.

Providers of lifestyle weight management programmes.

Ensure monitoring focuses on sustaining changes in the longer term. Include the following in the data reported:

Ensure other measured outcomes reflect the aim of the programme and relate to factors that can support or contribute towards a reduction in BMI. These could include: improvements in diet and physical activity, a reduction in sedentary behaviour and improvements in self-esteem. (See National Obesity Observatory's standard evaluation framework for weight management interventions for examples of other possible outcome measures.)

Ensure data collection tools are validated for the age range or population group the programme addresses and are feasible and affordable in practice settings. Do not rely on self-reported measures of height or weight, or interpretations of BMI based on them.

Monitor any variation in the numbers recruited, numbers completing and the proportion of people retained by the programme, according to population subgroup.

Collect data on:

Commissioners should evaluate the service using data on outcomes and the cost of promotion and delivery.

Commissioners should regularly review monitoring and evaluation data and use it to amend and improve the service.