Evidence

Surveillance report 2018 – Obesity: identification, assessment and management (2014) NICE guideline CG189 and BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups (2013) NICE guideline PH46

Surveillance decision

Surveillance decision

This 2018 surveillance review has taken into account 2 NICE guidelines on the theme of weight management:

Reason for the decision

The evidence

The surveillance review found 391 studies for NICE guideline CG189 and 66 studies for NICE guideline PH46.

No published evidence was identified that impacted on PH46. Published evidence that could affect recommendations was identified for CG189. We judged the impact of the new evidence on the following sections of the guideline with consideration of feedback from topic experts.

Identification and classification of overweight and obesity

NICE guideline CG189 advises using body mass index (BMI) as a practical estimate of adiposity in adults, but to interpret BMI with caution because it is not a direct measure of adiposity. It also advises consideration of using waist circumference (WC), in addition to BMI, in people with a BMI less than 35 kg/m2.

New evidence and expert feedback indicating the superior discriminatory value of waist to height ratio (WHtR) as an alternative measure of adiposity has a potential impact on recommendations 1.2.2 and 1.2.3, to review the alternative measures.

Topic expert feedback, NHS England and NICE accredited commissioning guidance also indicates that recommendation 1.2.1, advising the use of clinical judgement to decide when to measure a person's height and weight, requires review. Experts advised that instructions to clinicians, especially GPs, to measure BMI should be firmer, to facilitate the implementation of NICE's quality standard on obesity: clinical assessment and management. Experts advised that, to aid implementation, consideration should be given to aligning recommendation 1.2.1 with the British Obesity and Metabolic Surgery Society Commissioning guide: Weight assessment and management clinics (tier 3) which advises measuring BMI and WC if BMI is less than 35 kg/m2.

It is also proposed that recommendation 1.2.1 be updated to consider active case finding to detect obesity in black, Asian and other minority ethnic groups. The rationale is that there is an increased risk of adverse health conditions in this population at different thresholds compared to other populations. There is a risk that adverse health conditions in black, Asian and other minority ethnic groups may not be identified using opportunistic identification as currently recommended in NICE guideline CG189.

Decision: This area of the guideline should be updated.

Assessment

The collective new evidence, expert feedback and updated British Obesity and Metabolic Surgery Society Commissioning guide: Weight assessment and management clinics (tier 3) and NHS England commissioning guidance to support devolution to CCGs of Adult Obesity surgical services in 2016/17 indicate that there is a need for recommendations 1.3.7, 1.3.10–1.3.12 to cross refer to the commissioning guidance relating to tier 3 services. This should include a definition of tier 3 and 4 services, to be informed by expert input. See editorial and factual corrections in appendix A2 for further details.

Decision: This area of the guideline should be refreshed.

Pharmacological interventions

Liraglutide (Saxenda) was not licensed at the time of developing NICE guideline CG189 but has subsequently received a marketing authorisation for use in adults with obesity, up to a maximum dose of 3.0 mg per day. It is therefore a potential pharmacological treatment option for adults for whom lifestyle and behavioural approaches have not been effective and for whom the potential benefits of treatment outweigh the risks. In view of the new evidence supporting the use of liraglutide (Saxenda) in weight management, there is a potential impact on the guideline to update the pharmacological interventions section.

Decision: This area of the guideline should be updated.

Physical activity

Section 6 on physical activity was not updated at the time of developing NICE guideline CG189, with the recommendations carried forward from the original NICE guideline on obesity prevention published in December 2006. In order to provide up to date advice for physical activity, it is proposed that recommendations 1.6.1–1.6.8 be reviewed. This should include an evidence review on physical activity specific to obesity. The revised recommendations should also align with national advice from the Chief Medical Office (CMO) and link to NICE public health guidance on physical activity if judged relevant.

Decision: This area of the guideline should be updated.

Incorporation of recommendations from NICE guideline PH46

The surveillance review of NICE guideline PH46 has identified an overlap in the recommendations with those of NICE guideline CG189. Both guidelines include recommendations on the use of BMI and waist circumference for the identification and classification of overweight and obesity. NICE guideline PH46 extends these recommendations to black, Asian and other minority ethnic groups. Merging these guidelines will raise the awareness of recommendations for black, Asian and other minority ethnic populations and will not result in the loss of any unique information.

Decision: withdraw NICE guideline PH46 and incorporate the recommendations into NICE guideline CG189.

Overlaps with other guidelines

NICE's surveillance team assessed the extent of overlaps between NICE guideline CG189 and related guidelines in the areas of lifestyle, behavioural and physical activity interventions. The rationale and summary of proposed changes to address overlaps are as follows. Please see sections on overlaps with other guidelines and editorial and factual corrections in appendix A2 for further details.

Lifestyle interventions

Weight management: lifestyle services for overweight or obese adults (2014) NICE guideline PH53

Weight management: lifestyle services for overweight or obese children and young people (2013) NICE guideline PH47

There is overlap between NICE guideline CG189 and NICE guideline PH53 on weight management: lifestyle services for overweight or obese adults and NICE guideline PH47 on weight management: lifestyle services for overweight or obese children and young people. The overlap relates to the core components of lifestyle programmes for effective weight loss, choice and preference of treatment, training of health professionals and encouraging adherence. It is proposed that NICE guideline CG189 section 1.4 recommendations 1.4.1, 1.4.2 and 1.4.5 should cross refer to NICE guidelines PH53 and PH47 for additional information on lifestyle interventions for adults and children.

Behavioural interventions

Behaviour change: individual approaches (2014) NICE guideline PH49

There is a degree of overlap between NICE guideline CG189 and NICE guideline PH49 on behaviour change: individual approaches in the area of using proven behaviour change techniques in designing interventions, and ensuring interventions meet individual needs. A general cross referral from NICE guideline CG189 recommendation 1.5.1 to NICE guideline PH49 for adults and children is proposed for further information on delivering behavioural interventions with the support of an appropriately trained professional.

There is also an overlap between NICE guideline CG189 and NICE guideline PH49, relating to high intensity lifestyle interventions. It is proposed that NICE guideline CG189 recommendation 1.4.11 should cross refer to NICE guideline PH49 recommendation 9 for further information on high intensity interventions for obesity in adults at high risk of causing harm to their health and wellbeing, such as adults with a BMI more than 40.

Equalities

During consultation, inequalities by socioeconomic status and by age were highlighted. Stakeholders commented that there is potential for health inequalities to worsen if people with raised BMI are not identified, since overweight and obesity are disproportionately clustered in low income groups. This also extends to children and young people, who may not be adequately referred to appropriate weight management services. This was emphasised as a concern both in the short and long term due to tracking of excess weight from childhood into adolescence and adulthood.

During consultation, stakeholders commented that there is currently inequality in access to weight management services for people with learning disabilities and/or mental health problems. Comments also suggested that the referral and uptake of lifestyle interventions in black, Asian and other minority ethnic groups should be identified. However, the surveillance review did not find any evidence relevant to the identification of access to services or interventions for people with learning disabilities, mental health problems or people from black, Asian and other minority ethnic groups.

These points on inequalities will be passed to the guideline developers for consideration during the update.

Overall decision

After considering all the evidence and views of topic experts, we decided that a partial update is necessary for NICE guideline CG189 and to withdraw NICE guideline PH46 and incorporate the recommendations into NICE guideline CG189.

See how we made the decision for further information.


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