Overweight and obesity management

Why the committee made the recommendations

The committee noted a recurring theme in the evidence in that overweight and obesity can be complex and multifaceted, and can interact with many areas of a person's life. They agreed on the need to take this into account in all aspects of care, because weight cannot be addressed in isolation. Based on their experience, they discussed and agreed a non-exhaustive list of factors related to the wider determinants and the context of overweight and obesity that healthcare professionals need to take into account. Many of these reflect health inequalities that may limit a person's ability to address overweight or obesity and are outside their control. The evidence included many accounts of negative experiences in which healthcare providers did not take these factors into account, so the committee highlighted that it was important to keep the context of the person's health, social circumstances and their openness to engage with change at the forefront when making a professional judgement.

The committee looked at evidence on the stigma associated with being identified as living with overweight or obesity. This highlighted that many people had experiences in which healthcare professionals had talked about their weight in an insensitive manner. These experiences made them feel wary and defensive when weight was brought up in subsequent discussions with healthcare professionals. The committee agreed that these negative experiences could be reduced if the context and appropriateness of the discussion or appointment was taken into account before starting a discussion. They agreed it was also important to respect a person's choice not to discuss their weight. The committee also acknowledged that cultural factors and health professionals' own feelings and sensitivities about weight may be relevant in conversations.

The committee were also concerned that negative experiences of discussions about overweight or obesity can have a profound effect on how the person feels about themselves and risk perpetuating or triggering overemphasis on body image and size. They were also concerned that this could contribute to disordered eating or eating disorders in young people so agreed that conversations need to be tailored to age, maturity and understanding to reduce this risk. They stressed the importance of sensitivity in all discussions linked to overweight and obesity, and outlined steps that can help healthcare professionals have these conversations. The committee also highlighted the importance of using non-stigmatising language and images to promote a positive discussion, because stigma associated with obesity can affect people's mental and physical health. This can lead to further weight gain and make them less likely to engage with healthcare professionals. The committee noted existing resources and advice that could help conduct conversations in a sensitive and positive way.

How the recommendations might affect practice

Most of these recommendations reflect current good practice. In some areas extra NHS resources may be needed to bring services in line, particularly where services are underprovided. More training could also be needed.

The recommendations tackling stigma in particular are expected to reduce people's distress during appointments and routine health checks, which will improve their quality of life and make them more likely to attend follow-up appointments. So longer-term NHS savings from more efficient and accessible weight management services are expected to offset any initial investments.

Return to recommendations

Why the committee made the recommendations

The committee agreed that families and carers should take primary responsibility for behavioural changes in children and young people. But they recognised that it was appropriate for children to start to be empowered to manage their overweight or obesity around the age of 12, although this will vary depending on an individual child or young person's level of maturity and understanding. This is in line with NICE's guideline on babies, children and young people's experiences of healthcare, which highlights that children and young people under 16 can make decisions about their healthcare and consent to treatment if they are assessed to be Gillick competent.

The committee discussed situations in which weight or weight-related comorbidities posed a risk to the child or young person's health that would become a safeguarding concern if not addressed. They agreed that guidance was needed to assist with decisions that balance the need for person-centred care that respect the choice of child and young person (and that of their families or carers) about the care they receive with the duty of care to the child or young person when there is a serious risk to their long-term health.

The committee also considered the need to ensure that identifying the child or young person as living with overweight or obesity does not have a negative impact on them. The evidence highlighted that families and carers had concerns and anxieties about this, but there was little quantitative research measuring whether adverse effects occurred. The committee agreed this was an important gap in the evidence, so drafted a recommendation for research on the adverse effects of identification in children and young people, with a particular focus on the risk of developing eating disorders because they felt this was the most serious concern.

How the recommendations might affect practice

Most of these recommendations reflect current good practice. The recommendations tackling stigma in particular are expected to reduce distress during appointments and routine health checks, which will improve their quality of life and make people more likely to attend follow-up appointments.

Resources may be needed for extra processes to identify overweight and obesity in childhood and for increased referrals to emotional health and wellbeing support and services, but costs are expected to be offset by future savings and the benefits of more targeted interventions.

Return to recommendations

Why the committee made the recommendations

The committee reviewed findings from a very large evidence base on approaches to overweight and obesity prevention in children and young people. Despite the large volume of research, very few interventions showed evidence of effectiveness, particularly those that addressed diet or physical activity alone. They acknowledged that some interventions combining diet and physical activity components were effective, but overall the amount of change was small and not very clinically meaningful in reducing risk factors.

The National Child Measurement Programme, 2023/24 report showed that the children living in the most deprived areas were more than twice as likely to be living with obesity as those living in the least deprived areas. Obesity prevalence was also highest in children from a Black African, Black Caribbean or Bangladeshi background. The committee suggested that obesity prevention approaches in early-years and school settings were particularly valuable because these settings can help shape healthier lifelong attitudes and behaviours.

Based on their expertise and experience, the committee highlighted some important principles that would apply to all settings. They agreed that it was important to prioritise improving the nutrition and activity levels of children and young people, that a whole-school approach was most likely to be effective, and that it was vital to involve families and carers.

The committee also agreed on the need to include obesity prevention measures as early as possible in settings such as nurseries and childcare facilities. They suggested this ought to include minimising sedentary activities during play time, and providing regular opportunities for enjoyable active play and structured physical activity sessions. This is because reducing sedentary behaviour can play a key role in health promotion and obesity prevention. They discussed whether this principle would apply to all settings and agreed it was important to include schools.

There are also some steps that settings can take to encourage healthy eating. The committee discussed the benefits of staff supervising and eating with children at mealtimes; and ensuring children and young people eat regular, healthy meals in a pleasant, sociable and inclusive environment free from other distractions. They noted that food in early-years settings is not covered by the same statutory nutritional standards as school meals, but they agreed there is the same need to adapt catering in early-years settings to accommodate different cultural preferences and beliefs while maintaining nutritional standards. They also agreed it was important for settings to have reward strategies not based on food, to encourage children to develop a range of healthy motivational tools.

The committee discussed case study evidence showing a variation in the length of lunch breaks in schools and expressed concern that some schools have shortened the lunch break to 30 minutes. They were concerned that this may not allow children and young people adequate time to finish their meals and could also contribute to young people opting for unhealthier food choices, such as fast food, that can be consumed quickly. They did not identify evidence on a specific length of time that children and young people need to finish their meals, but agreed it was still important to highlight this issue.

The committee noted that many commercial obesity prevention interventions are available for local authorities to use in schools and early-years settings. They reflected on the considerable growth in the number of interventions available but noted that a limited number have been found to be clinically and cost effective. They agreed on the need for local authorities to look at evidence for the intervention when deciding whether to use it.

Some local authorities have developed and implemented their own interventions, based on the principles of obesity prevention. The committee suggested some other guidance and resources that can be used to develop effective interventions. Although the evidence did not identify 1 specific approach to obesity prevention that was effective, the committee agreed various factors that could help. These included taking into account the views of children and young people, any differences in preferences based on sex, culture or belief, and any individual medical or sensory needs.

The committee also highlighted the importance of adapting physical education, sport and other physical activity for children and young people with special educational needs and disabilities (SEND) to promote inclusion and minimise health inequalities.

The committee did not make any recommendations for further research because there is already a large evidence base in this area. But they noted that it was important for future research to focus on outcomes such as changes in the prevalence of overweight and obesity, rather than BMI alone, because this may be more accurate in determining the effectiveness of interventions.

How the recommendations might affect practice

The recommendations are in line with current practice and are unlikely to lead to a significant cost impact. The links to guidance and resources could help staff plan interventions.

Return to recommendations

Why the committee made the recommendations

The committee reviewed evidence on risk factors for people from Black, Asian and other ethnic minority backgrounds. There was very little direct evidence but, based on their experience, the committee agreed that people from Black and Asian backgrounds – as well as people from many ethnic minority backgrounds not covered by the evidence – have a higher risk of central adiposity and have an increased cardiometabolic health risk and risk of weight-related health conditions at lower BMI thresholds. They agreed that it was important to ensure that this information was explained in suitable formats and shared with the individuals and communities affected so they could take action to reduce these risks. They also noted the need to raise awareness of these risks among healthcare professionals.

The committee also agreed there was a need for more robust information about effective and acceptable approaches to identifying people from ethnic minority backgrounds who are at risk from overweight or obesity. So they made a recommendation for research on identification in people from ethnic minority backgrounds to inform future guidance.

How the recommendations might affect practice

Raising awareness of the use of lower BMI thresholds in people from Black, Asian and other ethnic minority backgrounds may increase the number of people who use overweight and obesity management services. But this could reduce levels of overweight and obesity, and thereby reduce the costs of treating related conditions for the NHS and wider system, including social care systems that are particularly affected by long-term conditions associated with obesity.

Return to recommendations

Why the committee made the recommendations

Evidence on diagnostic overshadowing (attributing symptoms to weight rather than a potential comorbid condition that could be unrelated) showed that people often felt that the issue they presented with was neglected in favour of discussions about weight, which could be stigmatising and unhelpful. Lay members on the committee confirmed that this was a very common experience. The studies showed that people felt it was important that healthcare professionals address the presenting condition first, before raising the topic of weight.

The evidence showed that consent and choice in whether to discuss weight was a key factor in whether people found conversations constructive and respectful, or stigmatising and intrusive. The committee agreed their experience aligned with this finding and that it was important for healthcare professionals to ask permission before discussing weight, to acknowledge that some people will not want to be weighed or to be told their weight, and to respect people's wishes on these points.

They also noted the need to measure waist circumference in people with a BMI below 35 kg/m², in accordance with the section on taking measurements. This is in line with advice provided in Public Health England's guidance on adult weight management: short conversations with patients, which also promotes weight being measured, recorded and discussed as part of routine consultation.

How the recommendations might affect practice

Weight and height might be measured more often, possibly increasing the length of appointments. Changes to how and when weight is discussed could help people feel less stigmatised, and therefore more welcoming of an intervention that could have a positive effect on both their health and NHS resources in the long term.

This more flexible approach is not expected to increase NHS and other public sectors resources significantly. It is expected to lead to more appropriate and up-to-date measurements being recorded. This will increase efficiency in identifying people living with overweight or obesity, and. It may also lead to more efficient and meaningful data analysis and the sharing of good practice.

Return to recommendations

Why the committee made the recommendations

The committee looked at evidence from studies on the accuracy of different measures for predicting or identifying health conditions associated with overweight and obesity, including type 2 diabetes and cardiovascular disease. The quality of the evidence was mixed. Most studies included information on how accurate the measures were at predicting or diagnosing the health risks associated with overweight and obesity, in people of different ethnicities. Overall, the studies showed that BMI, waist circumference, waist-to-hip ratio and waist-to-height ratio could all accurately predict or identify weight-related conditions. The committee noted that BMI is still a useful practical measure, particularly for defining overweight and obesity. But they emphasised that it needs to be interpreted with caution because it is not a direct measure of central adiposity. The committee highlighted that waist-to-height ratio offers a truer estimate of central adiposity by using waist circumference in the calculation. Based on evidence and their experience, they agreed that using waist-to-height ratio as well as BMI would help give a practical estimate of central adiposity in adults with BMI under 35 kg/m². This would in turn help professionals assess and predict health risks. But because people with a BMI over 35 kg/m² are always likely to have a high waist-to-height ratio, the committee recognised that it may not be a useful addition for predicting health risks in this group.

How the recommendations might affect practice

Encouraging self-measurement is in line with recent changes in practice, particularly the increase in carrying out initial assessments by phone. It has already become standard practice to use self-reported measurements such as weight, blood pressure readings and blood sugar levels for conditions like diabetes.

Using waist-to-height ratio as well as BMI would be likely to have minimal cost impact because tape measures are already routinely available in NHS settings for measuring waist circumference.

Community pharmacies have been involved in taking measurements as well as it being done in general practice. NHS England's Healthier weight competency framework highlights that healthcare professionals involved in identification of overweight and obesity should be able to accurately measure and classify weight status. With the addition of waist-to-height ratio, it is important that training is available so that measurements can be taken by trained personnel.

Currently, there are no established NHS calculators for waist-to-height ratio. But resources such as the NHS obesity page can be used to explain how to take waist measurements and calculate the ratio. Extra training programmes may need to be developed to help healthcare professionals understand central adiposity and conduct waist measurement in a sensitive manner and with care, especially in people with specific conditions such as eating disorders. This will increase training costs. There may also be a cost increase associated with the extra staff time needed to teach people how to measure themselves and calculate waist-to-height ratio. But the committee agreed that these extra costs are unlikely to result in a significant resource impact and will be balanced out by the long-term health improvements such as decreased risk of developing diabetes or cardiovascular disease.

Return to recommendations

Why the committee made the recommendations

BMI is the main measure for defining overweight and obesity, and the committee did not alter the BMI categories for the general population. But, based on their expertise, they agreed it was important to estimate central adiposity when assessing future health risks, including for people whose BMI is in the healthy weight category. The committee also highlighted the need for caution when interpreting BMI in adults with high muscle mass because it may be less accurate in this group.

Age-related changes in the body are not well captured by BMI. The committee agreed that BMI should therefore be interpreted with caution in people aged 65 and over, because their functional capacity may be reduced because of conditions such as age-related spinal disorders or sarcopenia. They also recognised that slightly higher BMI in older people can have a protective effect (for example, reduced risk of all-cause mortality) because they are less likely to be experiencing undernutrition. So it is important for professionals to evaluate the balance of these risks when interpreting BMI.

The committee also highlighted that people from Black, Asian and minority ethnic family backgrounds are prone to central adiposity and have an increased cardiometabolic health risk at lower BMI thresholds. For example, studies in people of South Asian and Chinese family backgrounds showed an increased risk at a BMI of 21 kg/m² to 26 kg/m², whereas people from White family backgrounds showed increased risks at 25 kg/m² to 29 kg/m².

There was also some evidence for using lower BMI thresholds for people from Middle Eastern (Arab and Iranian), Black African, Black Caribbean and other Asian (Japanese, Korean and Thai) family backgrounds. For these groups, studies identified an increase in risk at BMI values that ranged from 21 kg/m² to 30 kg/m² but most were below 25 kg/m². The committee noted that these lower thresholds are in line with international guidance and are already used in practice to refer people from these family backgrounds to overweight and obesity services.

Although NICE found no evidence on the thresholds for obesity classes 2 and 3 in people of these family backgrounds, the committee consensus was that it is generally good practice to reduce the thresholds used for the general population by about 2.5 kg/m². This would mean that the threshold for obesity class 2 would be lowered to roughly 32.5 kg/m², and for class 3 to 37.5 kg/m² in these populations. Public Health England guidance on adult weight management and the British Obesity and Metabolic Surgery Society guidance on accessing tier 4 services also endorsed reducing the thresholds.

In line with their recommendations for other populations, the committee used the terms overweight and obesity instead of risk levels to describe thresholds in people with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African–Caribbean family background. They agreed that in their experience there was more stigma attached to talking about risk than overweight or obesity. They noted that terms such as 'high risk' could result in anxiety and overinterpretation of risk more than terms such as 'living with obesity'.

The committee also discussed the accuracy of waist-to-height ratio boundary values in predicting and identifying health risks. The evidence showed that the cut-off from individual studies was generally around 0.5 for all ethnicities and sexes, which was in line with the wider evidence. They agreed that waist-to-height ratio could be used to define central adiposity in adults, and that a range of 0.5 to 0.59 corresponds to increased health risks. The committee noted that a waist-to-height ratio of 0.6 or more indicates a further increase in risk.

The committee agreed that a key benefit of using waist-to-height ratio is that the classification is the same for all ethnicities and sexes. It can also be useful in adults with high muscle mass, for whom BMI may be less accurate.

The committee also noted the boundary value of 0.5 could be communicated in a simple and memorable way with the message: 'keep your waist to less than half your height'.

Although there was a large evidence base, the committee noted a lack of evidence on the accuracy of methods for predicting future risks for people of some ethnicities. Few studies were based in the UK, so the evidence might not reflect how accurate different measures might be when used in a UK context. Therefore, the committee highlighted the need for more research on measurements and boundary values for different ethnicities and made a recommendation for research on measurements for assessing health risks in adults.

How the recommendations might affect practice

Using lower BMI thresholds in people from Black, Asian and minority ethnic family backgrounds will increase the number of people who are eligible for overweight and obesity services. But this could reduce levels of overweight and obesity, and thereby reduce the costs of treating obesity-related conditions for the NHS and wider system, such as social care systems.

There may be challenges in using BMI or waist-to-height ratio in people who have a physical disability, some physical conditions (such as scoliosis) or learning disabilities because people may be unable to get on scales independently or be lifted safely. In such circumstances, reasonable adjustments would be needed for adults, for example using seated or hoist scales, or scales that can used for wheelchairs (including moulded wheelchairs). Measurements may also need to be modified, for example using sitting height or demi-span (the distance between the mid-point of the sternal notch and the finger roots with the arms outstretched laterally) instead of overall height, meaning specialist assessment may be needed. It may also be challenging to take measurements in people who are housebound because it may not be possible to access equipment such as specialist scales during home visits.

Return to recommendations

Why the committee made the recommendations

There are 2 established programmes for identifying overweight or obesity in children and young people. The Healthy Child Programme measures children under 5, and the National Child Measurement Programme measures children aged 4 to 5 and 10 to 11 while they are at school. The committee noted that measurements from these programmes are often not given to families or carers or to their GPs, so they are often not followed up. So they agreed it was important for identification to also take place outside these programmes. The committee also recognised that processes were needed to identify obesity and overweight in children and young people outside the age groups measured by the National Child Measurement Programme, and those who are not in mainstream state education (for example, some children with SEND or some looked-after children) and so are not covered by the programme.

The evidence reviewed showed that adults often felt that when they presented with another health issue this was neglected in favour of discussions about weight, which could be stigmatising and unhelpful. Although there was no direct evidence for children and young people, the committee agreed – based on their experience and expertise – that these groups were likely to have similar experiences.

The committee's experience aligned with the evidence that parents who did not have the opportunity to consent to their child's measurements being taken experienced negative emotions if they were told their child was living with overweight or obesity. So they decided that it was important to ask children and young people, and their families and carers, for permission to discuss weight.

The committee agreed it was particularly important to record measurements for children and young people because measures of growth are essential markers of general health and development. They therefore highlighted some scenarios when measurements could be taken by a range of practitioners. This is in line with the Public Health England's guidance on short conversations with children and their families about weight management.

The committee discussed measuring and calculating waist-to-height ratio while taking other measurements in children and young people. There is evidence supporting this approach in adults, but it is less established for children and young people. So, based on their expertise and experience, they concluded it should only be used to supplement the standard height and weight measurements. They also discussed the possibility that some children and young people could potentially calculate their own waist-to-height ratio. But because there was no evidence and no clear consensus on either the effectiveness or the acceptability of this, the committee made a recommendation for research on using waist-to-height-ratio self-measurements in children and young people.

The committee discussed and agreed with the advice in Public Health England's guidance on conversations with children and their families about overweight and obesity management. This states that when families or carers seek overweight and obesity management based on the letter informing them of their child's National Child Measurement Programme results, the measurements should be repeated to ensure that records are kept up to date.

How the recommendations might affect practice

It is possible that weight and height will be measured more often, which could lead to longer appointments. But this is expected to lead to better identification of children and young people living with overweight or obesity, which could reduce costs in the longer term. So this is not expected to increase NHS resources significantly.

Return to recommendations

Why the committee made the recommendation

The committee looked at evidence on the accuracy of different measures for predicting or identifying health conditions associated with overweight and obesity, including type 2 diabetes and cardiovascular disease. The quality of the evidence was mixed. Some studies included information on how accurate measures were at predicting or diagnosing the health risks associated with overweight and obesity in children and young people of different ethnicities.

Overall, the committee agreed that the studies showed that BMI, waist circumference and waist-to-height ratio could all be used to accurately predict or identify weight-related conditions when they were adjusted for age and sex. The same was true of waist-to-height ratio when it was not adjusted for age and sex. They discussed that BMI z-score adjusted for sex and age tended to be the most accurate measure for identifying different health conditions, but waist-to-height ratio was often equally accurate and, in some studies, more accurate. (BMI z-score is also known as BMI standard deviations [SDs], which indicate how many units a child's BMI is above or below the average BMI value for their age group and sex.)

Based on the evidence and their clinical expertise, the committee agreed that BMI is a useful practical measure for estimating and defining overweight and obesity. However, they noted that BMI should not be interpreted in the same way for children and young people as for adults. Healthcare professionals should use charts that are specific to children and young people and adjusted for age and sex. The committee also noted that waist-to-height ratio is a truer estimate of central adiposity, which is related to health risks.

The committee agreed that special growth charts may be needed when assessing children and young people with cognitive and physical disabilities, including those with learning disabilities. They noted that growth charts for children and young people with Down's syndrome are available from the Centres for Disease Control and the Royal College of Paediatrics and Child Health.

The committee agreed that the evidence for using waist-to-height ratio as a practical estimate for central adiposity to assess and predict health risk in children and young people was not as good as the evidence for adults. They agreed that it could still be useful as an indication of future health risks. But they stated that more research was needed on the accuracy of different measures and made a recommendation for research on measurements for assessing health risks in children and young people.

How the recommendation might affect practice

There may be challenges in using BMI or waist-to-height ratio in children and young people with physical disabilities, some physical conditions (such as scoliosis) or learning disabilities. Reasonable adjustments would also be needed for children and young people using wheelchairs (including moulded wheelchairs) such as using seated or hoist scales, or scales that are suitable for wheelchairs. And although there is published guidance on supporting people with learning disabilities in overweight and obesity management, there are no validated proxy measurements for height in children and young people (for example, using their sitting height or demi-span to estimate their height). This makes taking measurements difficult in children and young people with physical disabilities or learning disabilities.

Return to recommendation

Why the committee made the recommendations

The committee looked at evidence for different boundary values for BMI and BMI z-scores but these focused on identifying current health conditions rather than defining the degree of overweight and obesity. Based on their expertise, they provided clinical definitions of overweight and obesity using BMI centiles and BMI SDs. These values correspond with those in the Royal College of Paediatrics and Child Health UK-World Health Organization growth charts. The committee agreed that it was important to use clinical judgement when interpreting BMI below the 91^st centile, especially because children and young people in the healthy weight category may still have central adiposity.

The committee also noted that there are resources that can help professionals understand how to measure, plot and assess BMI in children and young people. These include educational resources from the Royal College of Paediatrics and the National Child Measurement Programme Operational Guidance, which both give information on how the clinical definitions of BMI link to BMI centiles and SDs.

There was a lack of evidence identified on BMI boundary values for children and young people from different ethnicities. The committee agreed this was an important area for research to investigate whether there are variations in thresholds, as there are in adults, and made a recommendation for research on measurements for assessing health risks in children and young people. The committee noted that although they could not provide different thresholds for BMI, waist-to-height ratio could be used as an indicator of central adiposity regardless of ethnicity and sex.

Studies also suggested that the optimal waist-to-height ratio cut-offs for children and young people ranged from 0.42 to 0.57, with most studies averaging around 0.5. Based on the evidence and their clinical knowledge, the committee agreed the waist-to-height ratio boundary value of 0.5 should be the same for children and young people as for adults.

How the recommendations might affect practice

Waist-to-height ratio is not routinely measured in practice so there may be extra costs for the extra staff time involved. But the cost impact should be small because waist measurements are already widely used in primary care so it would not need much extra time to calculate the ratio.

Health visitors and school nurses, as well as general practice, are involved in taking measurements. The NHS England healthier weight competency framework does highlight that healthcare professionals involved in identification of overweight and obesity should be able to accurately measure and classify weight status in children and young people. With the addition of waist-to-height ratio, it is important that training is available so that measurements can be taken by trained personnel.

The NHS obesity page, and organisations such as Diabetes UK and the British Heart Foundation, have information and videos explaining how to measure and calculate waist-to-height ratio. These are for adults but can also be useful for older children and young people, families and carers.

Return to recommendations

Why the committee made the recommendations

Based on their experience, the committee agreed that before deciding on referral for adults it was important to discuss and agree realistic and appropriate health goals, and to emphasise the importance of personal choice and person-centred care. They also highlighted that in their experience interventions were more likely to be effective if they address the drivers of overweight and obesity, for example social context, mental health and wellbeing and stigma. They discussed what form appropriate goals should take, and agreed that it was more useful to focus on wider health goals and benefits rather than only on weight. They highlighted the importance of making the person's individual needs and preferences the main concerns when setting goals.

How the recommendations might affect practice

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. Resources may be needed for increased assessments for any comorbidities, or referral to other services such as social care, physiotherapy, eating disorder services or other physical or mental health and wellbeing support. But the cost of this is expected to be insignificant and be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendations

The evidence showed that, in many areas, there were very few overweight and obesity management services and, if they were available, healthcare professionals were often not aware of them. The committee noted that the availability of services is an issue in many areas across the UK and highlighted that, for services to be used effectively, it was important for healthcare professionals involved in identifying overweight and obesity to be aware of them.

Based on their understanding of practice, the committee stressed the importance of an all-round discussion of the person's individual needs and preferences to reach a shared decision about what level and types of intervention would suit them. This includes taking into account factors such as ethnicity, weight-related comorbidities, socioeconomic status, family medical history and special educational needs and disabilities (SEND). These discussions can also involve giving information about local overweight and obesity services and other support services.

There was a wealth of evidence on what types of intervention adults wanted and how these could be tailored to meet their needs. In light of this, the committee agreed it is most effective to use interventions that are culturally appropriate, tailored to particular demographic groups, and that take people's previous experience of interventions into account. They also agreed that people were more likely to engage with interventions if they understood why these adaptations could help them. The evidence showed that men were a particular demographic group who benefit from targeted interventions, so the committee highlighted men-only interventions as a specific adaptation that would be useful.

The evidence revealed that adults are often worried about the costs of taking part in an intervention. The committee were concerned that costs can be a barrier to participation that widens health inequalities. So they agreed it was important to inform adults about any known costs associated with the intervention, or with continuing it after a funded referral period has ended.

It is widely thought that group interventions tend to be more cost effective than individual ones, but no direct evidence was found to support this. Although there was no evidence on the cost effectiveness of digital services, the committee agreed that in their experience these are a useful additional option and are preferred by some people. The committee noted that there are rarely enough interventions available locally to enable a choice. But they agreed that, if a choice was possible, it was appropriate to base the decision on whether to use an in-person individual or group intervention, or a digital intervention on the person's preferences and needs.

Committee consensus was that a holistic approach was key to making sustainable changes, and that people need information about extra sources of long-term community or healthcare support. This reflects the approach recommended in NICE's guideline on behaviour change: digital and mobile health interventions.

How the recommendations might affect practice

The recommendations are not expected to need a significant increase in capacity and resource. Healthcare professionals should already be aware of the overweight and obesity management services that are available locally and nationally. The more flexible approach is expected to lead to a more appropriate choice of intervention in people living with overweight or obesity.

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendation

Based on their expertise, the committee agreed people with weight-related comorbidities may benefit from a higher level of intervention. They also highlighted groups of people, such as those newly diagnosed with type 2 diabetes and those with BMI over 50, who would benefit more from immediate overweight and obesity interventions. Based on their expertise, the committee noted that these groups are often not offered appropriate interventions early enough.

How the recommendation might affect practice

The recommendation is not expected to need a significant increase in capacity and resource. Healthcare professionals should already be aware of the overweight and obesity management services that are available locally and nationally. The more flexible approach is expected to lead to a more appropriate choice of intervention in people living with overweight or obesity.

Back to recommendation

Why the committee made the recommendations

The committee emphasised the need to acknowledge and respect the person's choice to decline a referral. The evidence showed that adults often find it stigmatising when they feel pressured to engage with overweight and obesity management. The committee were concerned this would create barriers to engagement with interventions. They agreed it was also important to offer further opportunities for referral or re-referral, because evidence indicates that overweight and obesity can be long-term, relapsing issues.

How the recommendations might affect practice

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendation

The committee agreed that it is important to ask for permission from children, young people, and their parents or carers (if appropriate), before starting any discussions linked to overweight, obesity or central adiposity. They agreed that professional judgement is needed to ensure discussions are age appropriate and decide whether the child or young person should be involved. They also noted that it was standard practice for healthcare professionals to use Gillick competency to determine the capacity of a child or young person under 16 to consent.

How the recommendation might affect practice

There are a few training programmes specifically for managing overweight and obesity in children and young people, such as the training by the World Obesity Federation, European Childhood Obesity Group, the Department of Health and Social Care's obesity team and Health Education England. Some of these need to be updated to include measuring waist circumference and interpreting waist-to-height ratio, which might lead to extra training costs. Healthcare professionals may need extra time to teach older children and young people, and their families and carers, how to measure the waist accurately and calculate waist-to-height ratio. However, the committee agreed that extra costs of training and staff time are unlikely to result in a significant resource impact and are justified by the long-term health benefits associated with a reduction in obesity-related conditions.

Return to recommendation

Why the committee made the recommendations

The evidence showed that children and young people and their families or carers were not always keen to accept a referral to overweight and obesity management interventions. The committee therefore highlighted the need to explain the health risks associated with a higher BMI using non-judgemental language, to consider the drivers of overweight and obesity and to advocate for the child's health in proportion to the impact their BMI may have. In their view, the higher the child's BMI the greater the risks. So they agreed it was important to convey this to families and carers to encourage engagement.

There was some evidence that beliefs and attitudes about weight stemming from different cultural contexts and backgrounds influenced how families and carers felt about their child being identified as living with overweight or obesity, or with being referred. But this evidence was not specific or comprehensive, so the committee made a recommendation for research on beliefs about weight to investigate these factors further so they can be given the appropriate respect and depth of consideration in future.

Based on their experience, the committee agreed on the need to discuss and set realistic and appropriate health goals and to emphasise the importance of personal choice and person-centred care before deciding on referral. This would help people make the most suitable choice. The committee discussed what form these goals should take, and they highlighted the importance of making the person's individual needs and preferences the main concerns. They agreed that for children and young people it was particularly important not to make lowering BMI or weight the only goal, because the evidence indicated that interventions are unlikely to reduce BMI in the long term.

The committee agreed that any intervention in children and young people should also include support for weight maintenance, as evidence on diet interventions suggested that interventions that included support were more likely to be beneficial and cost-effective. They also emphasised discussing wider benefits, including improvements in psychosocial outcomes such as sense of wellbeing, self-efficacy, self-esteem, and self-perception, because the evidence showed that children and young people consider these to be important.

The committee wanted to encourage referral and uptake of alternative services, including the local mental health pathway and other specialist services that may help address the determinants of overweight and obesity. The committee highlighted mental health support in particular, because this was a concern raised in the qualitative evidence. Mental health was found to have a negative impact on access to services.

How the recommendations might affect practice

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

A focus on addressing the drivers of overweight and obesity is likely to increase the effectiveness and cost effectiveness of the interventions.

Back to recommendations

Why the committee made the recommendations

The committee agreed that healthcare and other professionals need to be familiar with the local overweight and obesity management pathway for children and young people, especially links to support services, so they can give accurate and pertinent advice to best meet children and young people's needs.

The committee agreed, based on evidence and their experience, that discussions of previous overweight and obesity management experiences were more effective if they take into account cultural and social assumptions about health and diet, and the impact of deviating from these to achieve better health. They noted the need to address these points before choosing an overweight and obesity management intervention. They agreed it was also important to discuss how both the child or young person and their family or carers feel about overweight and obesity management, including specific interventions, so that all views could be taken into account to enable person-centred care. Finally, they wished to emphasise that it is the choice of the child, young person, families or carers whether to accept a referral.

There was a wealth of evidence on what types of intervention children and young people, and their families and carers, wanted and how these could be tailored to meet their needs. So, the committee agreed that adherence could be improved if referrers identify interventions that are culturally appropriate, have been adapted for different cultural communities and dietary practices, or are tailored to particular demographic groups. Children and young people expressed a particular desire for peer support in the interventions, so being among their own age group was one important concern when choosing an intervention.

As with adults, the committee were concerned that costs can be a barrier to participation that widens health inequalities. So they agreed it was important to inform people about these as well as the importance of regular attendance before they make decisions.

Network meta-analyses of the evidence showed that changes to children's BMI z-score as a result of an intervention were not sustained. (BMI z-score is also known as BMI standard deviations [SDs], which indicate how many units a child's BMI is above or below the average BMI value for their age group and sex.) There was little or no difference between BMI z-score at the start of an intervention and BMI z-score 6 months or more after it ended. This aligned with the committee's view that, in their experience, overweight and obesity can often be long-term issues, and weight regain is common. They agreed that referring to interventions that offer ongoing maintenance advice and support gave the best possible chance of making sustained changes. But they noted that more evidence was needed to support this view, so made a recommendation for research on behavioural interventions and long-term support in children and young people.

Based on their clinical expertise, the committee agreed that tailored interventions were useful for children who are living with overweight or obesity or have increased health risk based on waist-to-height ratio. They agreed that weight-related comorbidities, ethnicity, socioeconomic status, social complexity (for example, looked-after children and young people), family medical history, mental and emotional health and wellbeing, developmental age, and special educational needs and disabilities (SEND) need to be taken into account when tailoring interventions.

How the recommendations might affect practice

Time will be needed to for practitioners to familiarise themselves with the local overweight and obesity management pathway. And discussing this is likely to increase the length of appointments. But the cost is expected to be offset by savings from better health outcomes.

Providing weight maintenance support after a weight management intervention may initially need additional resources, but it is expected to reduce relapses and downstream costs related to obesity management, which will increase the overall efficiency of the NHS.

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

There might be some costs associated with the whole-systems approach to embedding overweight and obesity management interventions into wider programmes that involve multi-partnership and integration of care. But a focus on addressing the drivers of overweight and obesity is likely to increase the effectiveness and cost effectiveness of the interventions.

There are a few training programmes specifically for managing overweight and obesity in children and young people, such as the training by the World Obesity Federation, European Childhood Obesity Group, the Department of Health and Social Care's obesity team and Health Education England. Some of these need to be updated to include measuring waist circumference and interpreting waist-to-height ratio, which might lead to extra training costs. Healthcare professionals may need extra time to teach older children and young people, and their families and carers, how to measure the waist accurately and calculate waist-to-height ratio. However, the committee agreed that extra costs of training and staff time are unlikely to result in a significant resource impact and are justified by the long-term health benefits associated with a reduction in obesity-related conditions.

Return to recommendations

Why the committee made the recommendation

The committee were particularly aware that children and young people with weight-related comorbidities, such as type 2 diabetes, may benefit from a higher level of intervention regardless of their waist-to-height ratio. The committee stressed the importance of working with the child or young person, and their families and carers (if appropriate), to make an informed decision about the treatment or care option that is best for them. As highlighted in resources such as the step-by-step guide produced by Public Health England on conversations about weight, healthcare professionals can also give information about local overweight and obesity services such as complications from excess weight clinics (CEW) (if available) and other paediatric support services during these discussions.

How the recommendation might affect practice

There are a few training programmes specifically for managing overweight and obesity in children and young people, such as the training by the World Obesity Federation, European Childhood Obesity Group, the Department of Health and Social Care's obesity team and Health Education England. Some of these need to be updated to include measuring waist circumference and interpreting waist-to-height ratio, which might lead to extra training costs. Healthcare professionals may need extra time to teach older children and young people, and their families and carers, how to measure the waist accurately and calculate waist-to-height ratio. However, the committee agreed that extra costs of training and staff time are unlikely to result in a significant resource impact and are justified by the long-term health benefits associated with a reduction in obesity-related conditions.

Return to recommendation

Why the committee made the recommendation

The committee noted that the wider determinants and context of overweight and obesity can influence people's ability to accept a referral, and they discussed the need to acknowledge and respect the choice to decline a referral. They agreed that it was particularly important to offer further opportunities for referral or re-referral to children and young people, because their weight status is still in flux while they grow, so it is important to keep monitoring whether their growth is following a healthy trajectory.

How the recommendation might affect practice

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

There might be some costs associated with the whole-systems approach to embedding overweight and obesity management interventions into wider programmes that involve multi-partnership and integration of care. But a focus on addressing the drivers of overweight and obesity is likely to increase the effectiveness and cost effectiveness of the interventions.

Return to recommendation

Why the committee made the recommendations

The committee did not review evidence on encouraging adherence for adults, but they agreed that the overall principles derived from the evidence for children and young people applied equally to adults.

They discussed how best to address concerns or barriers that may affect the person's attendance and participation in behavioural interventions. They also agreed it was useful to repeat these discussion points from the initial referral to ensure consistency in approach throughout the process. Likewise, when reviewing progress towards meeting goals they agreed it was important to continue to focus on health goals, rather than focusing solely on weight goals, and address any difficulties that affect the person's attendance and participation. If difficulties cannot be resolved, they agreed that alternative options, such as referral to another service, could help people maintain adherence.

The committee recognised that the support from family and others such as friends and peers can improve adherence and help the person achieve their goals. They also highlighted the importance of sharing information with the referring GP or healthcare professional so they can also provide continued support if necessary.

How the recommendations might affect practice

The extra time needed to discuss overweight and obesity management options and address any barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendation

The committee noted the importance of entering participant data into the National Obesity Audit, to drive improvement in the care available to those living with overweight and obesity in England.

How the recommendation might affect practice

Submitting data to the National Obesity Audit should be standard practice, so will not need extra resources in areas that already meet this obligation.

Return to recommendation

Why the committee made the recommendations

The committee recognised that it is not always possible to refer to interventions that continue to offer maintenance advice and support after an intervention ended. So they agreed that offering maintenance advice during the intervention that participants can follow once it is completed was an achievable way to ensure people had the information they need after the intervention finished.

They agreed interventions should be multicomponent and tailored to individual needs because the evidence suggested a variety of barriers that affect people's willingness to participate and adhere to the intervention, but that these barriers would be different for each person.

Based on the network meta-analyses, the committee agreed that the evidence supported the effectiveness of interventions that included both diet and behaviour-change components. They also agreed it supported the effectiveness of several specific behaviour-change components, and of encouraging other family members to engage with the intervention.

Although there was no specific evidence to support a physical activity component of interventions, the committee agreed that based on their experience this was also likely to be a useful addition.

How the recommendations might affect practice

Providing weight maintenance support after a weight management intervention for children and young people may initially need additional resources, but it is expected to reduce relapses and downstream costs related to obesity management, which will increase the overall efficiency of the NHS.

There might be some costs associated with the tailored multicomponent approach to embedding overweight and obesity management interventions for children and young people. A focus on addressing the drivers of overweight and obesity is likely to increase the effectiveness and cost effectiveness of the interventions.

Return to recommendations

Why the committee made the recommendations

The committee considered the evidence on developing a tailored plan to meet individual needs. The studies supported the principles of tailoring plans to give individual, patient-centred care, and reinforced the need to take account of mental health and wellbeing needs.

How the recommendations might affect practice

The extra time needed to tailor plans and address barriers that affect uptake is likely to increase the length of appointments. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendations

The committee considered the evidence on encouraging adherence to behavioural overweight and obesity management interventions. The evidence outlined how accessibility, choice and convenience of the interventions (such as individual or group) could act as barriers or facilitators to attendance. The committee agreed this showed the importance of suitable venues, times, flexibility and consistency. They also used their expertise and experience to agree that maintaining contact with families and carers, and following up on any problems with attendance would support adherence.

The committee discussed how best to address concerns or barriers that may affect the child or young person's attendance and participation in the intervention. They agreed it was useful to repeat the discussion points from the initial referral to ensure consistency. Likewise, when reviewing progress towards meeting goals they agreed it was important to continue to focus on achievable health goals, rather than focusing solely on weight goals (which are less likely to be met), and to address any difficulties that affect the person's attendance and participation. If difficulties cannot be resolved, they agreed that alternative options such as referral to another service could help the child or young person maintain adherence.

How the recommendations might affect practice

The extra time needed to discuss adherence and follow up on problems is likely to increase the length of appointments. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendations

In the committee's experience, people need long-term support because overweight and obesity are chronic health conditions. But the majority of trials reviewed in the evidence used fixed term interventions with very little follow up and support afterwards. The committee made a recommendation for research on behavioural interventions and long-term support in children and young people to fill this gap in the evidence.

Based on their experience, the committee agreed that ongoing support is a necessary part of effective interventions and that this should be tailored according to the child or young person's progress, their needs and the needs of the family and carers, and information from monitoring the intervention. Their consensus was that this is best offered by intervention providers directly if possible, but that it is also useful to discuss other services that can give extra support with the child or young person, their family and carers. They noted the need for these external services to have staff with the appropriate skills and comply with local policies and requirements, such as safeguarding.

How the recommendations might affect practice

Extra time and resources may be needed for follow up and long-term support. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendations

Based on their experience and expertise, the committee highlighted the need for ongoing support from healthcare and other professionals throughout the child or young person's path to adulthood. They agreed that it is important to continue to measure and monitor the child or young person's weight, because overweight and obesity can be recurring issues and further support is needed if the child or young person's BMI begins to increase. They also agreed it was not practical to specify a timeframe for how long a child or young person should continue to be measured because that will depend on their age and needs. They noted the need for healthcare and other professionals to have the appropriate skills and comply with local policies and requirements.

How the recommendations might affect practice

Extra time will be needed for ongoing support and monitoring. But the cost of this is expected to be insignificant and to be offset by savings from better health outcomes.

Return to recommendations

Why the committee made the recommendation

The committee noted the importance of entering the required participant data into the National Obesity Audit, to drive improvement in the care available to those living with overweight and obesity in England.

How the recommendation might affect practice

Submitting data to the National Obesity Audit should be standard practice, so will not need extra resources in areas that already meet this obligation.

Return to recommendation

Why the committee did not make a recommendation

The use of psychological approaches, such as compassion focus therapy, cognitive behavioural therapy and acceptance and commitment therapy, varies among multicomponent overweight and obesity management services. NICE found little evidence about the effectiveness, cost effectiveness and acceptability of these approaches to address weight stigma in adults, and none for children and young people. The committee noted that the majority of the evidence was from pilot studies that had various problems, including very small sample sizes, and none of the studies were done in the UK.

The committee stressed the need for more studies using larger sample size and longer follow up (at least 1 year), so they made a recommendation for research on psychological therapies to address the effect of stigma so that robust recommendations could be made in the future on using these approaches.

Return to recommendations

Why the committee made the recommendations

Although the evidence focused on adults, the committee developed recommendations to cover all ages because the principles are important for everyone.

There was no evidence on how diets should be tailored to meet individual needs. So the committee used their expertise to highlight factors, such as food preferences, personal circumstances or comorbidities, that are key to a flexible, individual approach and can influence adherence and effectiveness. They also agreed that, in their experience, discussing the wider benefits of an improved diet also helped people follow the dietary advice.

The committee acknowledged that any dietary approach needs to reduce energy intake, and therefore most diets restrict food intake. But they were concerned that excessive restriction can result in poor nutritional balance. It can also contribute to rapid weight regain or weight cycling (repeatedly losing and regaining weight) in the long term. The committee noted that the calorie deficit in the studies varied. Many used a 500 to 800 kilocalories a day deficit but it was also common to use an individual deficit for each participant, so they agreed not to specify a particular deficit.

The committee recognised that macronutrient diets are increasingly popular, but they vary in the approach to macronutrient balance and the evidence did not favour a particular approach. They noted that many of the studies compared low-carbohydrate diets with 'conventional' diets that were typically low-fat. Generally, the evidence could not differentiate between the approaches. So the committee agreed they could not recommend specific types of macronutrient diets and that different approaches to lowering macronutrient content, by reducing either fat or carbohydrate intake, could be used to create the energy deficit needed.

The committee emphasised the importance of support from appropriately trained healthcare professionals such as Registered dietitians or UKVRN registered nutritionist administered by the Association for Nutrition as part of any dietary approach, because this can help people to achieve a nutritional balance and to maintain weight in the long term.

No evidence was identified on the effectiveness of plant-based diets so the committee could not make any recommendations on these. They also agreed that plant-based diets are often adopted for environmental or ethical reasons rather than for weight loss.

How the recommendations might affect practice

The recommendations reflect general principles of care and are largely in line with current practice, so are not expected to need extra resources.

Return to recommendations

Why the committee did not make a recommendation

Some evidence was identified on intermittent energy-restriction approaches such as alternate-day fasting and time-restricted eating. This showed improvement for a few outcomes, but for most outcomes it was not effective. The committee also noted the variation in approaches to intermittent energy restriction and that there were problems with the studies, such as not being able to differentiate between the intervention and control for some outcomes. So they did not make recommendations on these diets but made a recommendation for research on intermittent fasting in adults to encourage better quality trials.

Return to recommendations

Why the committee made the recommendations

The committee looked at evidence on a range of diet types, including low-energy, very-low-energy, low-carbohydrate, very-low-carbohydrate and intermittent energy-restriction approaches. It showed low-energy (800 to 1,200 kilocalories a day) and very-low-energy (fewer than 800 kilocalories a day) diets to be effective, with results lasting for 3 to 5 years after undertaking the diet if ongoing support is given.

In most of the studies, participants followed low-energy and very-low-energy diets for between 8 and 16 weeks, and most commonly for 12 weeks. So the committee agreed that neither approach should be used as a long-term strategy and should be followed for no more than 12 weeks. They emphasised that this should be explained to people before they start the diet.

The low-energy diets used in the evidence were either total meal replacement or partial meal replacement diets. They were more effective than usual care for both mixed populations (people living with overweight and people living with obesity) and for people with type 2 diabetes. The health economic analysis found low-energy diets plus weight maintenance support to be cost effective in people who are living with obesity, or who are living with overweight and have type 2 diabetes. So the committee agreed that low-energy diets were appropriate for both these groups.

Some evidence for low-energy diets was limited to people with type 2 diabetes diagnosed up to 6 years previously. But the committee were not aware of evidence on the relationship between the duration of type 2 diabetes and the likelihood of diabetes remission with weight loss, so they agreed not to limit use of these diets to people with a recent diagnosis. Because of the lack of evidence, they made a recommendation for research on low-energy diets in people with type 2 diabetes.

For very-low-energy diets, all studies were of total meal replacement diets in mixed populations (people living with overweight and people living with obesity). These diets were more effective than usual care in reducing weight and waist circumference. There was no evidence on partial meal replacement diets, or on using this diet in people with type 2 diabetes.

The committee agreed that very-low-energy diets were effective but stressed that, because of their restrictive nature, they should be used only for specific goals in populations who have a clinically assessed need to rapidly lose weight. They discussed whether to specify that this should include people who need joint replacement surgery or who are seeking support from fertility services, but there was a lack of evidence for these groups and the committee were concerned that specifying particular groups could be stigmatising or delay people from receiving treatment. Nevertheless, they recognised that weight loss can make some surgical procedures safer or more technically feasible. So they agreed to highlight the importance of surgical feasibility and safety (rather than access to services) as a reason someone might need to rapidly lose weight. Because of the lack of evidence on specific groups they also made a recommendation for research on low-energy and very-low-energy diets before treatment for other conditions.

The committee also noted that participants in the studies had support from trained healthcare professionals such as Registered dietitians and UKVRN registered nutritionist administered by the Association for Nutrition, physicians, counsellors or practice nurses. This covered the intervention period, food reintroduction (particularly if total meal replacement diets had been used), and long-term support with weight maintenance or if weight regain occurred. The committee's experience aligned with the evidence that ongoing clinical support and supervision is a critical part of a multicomponent overweight and obesity management strategy. Although the committee acknowledged that a Registered dietitian or UKVRN registered nutritionist administered by the Association for Nutrition are not necessary to deliver the diet, they agreed on the importance of facilitating access to people with this training if needed (for instance if people are concerned about rapid weight loss).

The committee discussed the high likelihood of weight regain, particularly when reintroducing food after total meal replacement diets. They agreed that, in their experience, being clear about the potential for weight regain or weight cycling (repeatedly losing and regaining weight) helped manage people's expectations and normalise these outcomes. They emphasised the importance of reassuring people that weight regain is not a sign of failure, so they do not become discouraged, and of discussing other options for long-term weight maintenance.

The committee noted that there was no evidence of adverse events linked with low-energy and very-low-energy diets. But in their experience constipation, fatigue and hair loss are common and it is important to make people aware of the restrictive nature of these diets and the potential for adverse events so that they are prepared.

Although no evidence was identified on the development of eating disorders or disordered eating with restrictive diets, the committee raised concerns about their potential psychological impact. Based on their experience and stakeholder feedback, it is a common concern that people who show a preference for highly restrictive diets and fasting are more likely to be vulnerable to an eating disorder. So the committee agreed that it was important for healthcare professionals to think about assessment and counselling for eating disorders and other mental health issues before starting someone on a low-energy or very-low-energy diet. But they also stressed the importance of discussing potential benefits of these diets, including those beyond weight loss such as improvement in diabetes and other health benefits, so that people are not put off trying them.

Because of the limited evidence they made a recommendation for research on adverse events associated with different dietary approaches, including development of eating disorders or disordered eating and the psychological impact of 'yo-yo dieting' and weight fluctuations.

The committee acknowledged that people who are eligible for low- and very-low-energy diets may need to take medicines for other conditions. Dosages may need to be altered for people on these diets, especially if rapid weight loss occurs, so it is important for healthcare professionals to review any existing medicines and discuss any changes that may be needed.

How the recommendations might affect practice

People on low-energy diets and very-low-energy diets may need access to support from an appropriately trained Registered dietitian or UKVRN registered nutritionist administered by the Association for Nutrition, particularly when reintroducing food after meal replacement diets, or when weight regain happens. Changes in practice may be needed to ensure that people are supported to achieve and maintain a healthy weight and reduce the risk of harmful weight regain. But the benefits of long-term weight reduction are expected to outweigh any extra costs.

Offering low-energy diets to people who are living with obesity or people who are living with overweight who have type 2 diabetes will increase the number of people eligible for support from overweight and obesity management services. But reduced levels of overweight and obesity could reduce the costs of treating related conditions for the NHS and wider systems, such as social care.

The NHS Type 2 diabetes Path to Remission Programme provides a low-calorie, total meal replacement treatment in selected areas for people with type 2 diabetes who are living with obesity or overweight. Results from this will help to build knowledge and understanding about the use of these interventions and the impact they might have on the treatment of people with type 2 diabetes.

There may be cost implications for people who are eligible for total meal replacement diets if they have to pay for the products themselves. But because the diets are cost effective when financed and provided by the NHS, these recommendations are expected to encourage NHS commissioners to provide them free to eligible groups.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect practice

Offering assessment for bariatric surgery to people even if they have not tried all non-surgical measures or have not already attended a specialist overweight and obesity management service for intensive overweight and obesity management support will reduce variation in practice and increase uptake in previously overlooked groups. Considering assessment for bariatric surgery at lower BMI thresholds for people from some ethnicities will reduce inequalities in obesity-related outcomes and improve accessibility of treatment.

These are both likely to increase the number of referrals and surgeries carried out, and therefore increase costs. But basing the offer of surgery on comorbidities as well as BMI will help those who could benefit most, and the cost will be offset by the long-term reduction in obesity-related complications.

Return to recommendations

Why the committee made the recommendation

The committee discussed whether there should be an upper BMI or upper age limit for referral to overweight and obesity management services. Based on their expertise and experience, they agreed there should be no limits, but added that older adults or people with a very high BMI often had complex or specialist needs. Based on their experiences and judgement of the suitability of services, they agreed to emphasise the need for services to be accessible and able to meet complex needs.

How the recommendation might affect practice

The recommendation reflects general principles of care and is largely in line with current practice, so is not expected to have an impact on resources.

Return to recommendation

Why the committee made the recommendations

The committee discussed the need for commissioners and programme providers to be aware of local needs so that sufficient interventions are commissioned. They used their experience and expertise to suggest topics for public health information and details of interventions the public could be made aware of, and suggest routes for sharing this information. Raising professional and public awareness of what is available and maintaining an up-to-date list of local interventions will enable efficient referral and self-referral.

Based on their experience the committee discussed that healthcare professionals want to be able to share online and social media resources with adults. They agreed that many people prefer to access information about overweight, obesity and possible interventions online, so it is important for healthcare professionals to have reliable sources at hand.

How the recommendations might affect practice

The recommendations reflect general principles of care and are largely in line with current practice. Raising professional and public awareness could have a cost, but the benefits of better awareness are expected to offset any investment.

Return to recommendations

Why the committee made the recommendation

The committee reviewed evidence on who could best develop interventions, and agreed that the involvement of a multidisciplinary team was necessary. Based on their experience that services and available staff vary by area, and that the make-up of multidisciplinary teams needed to flexible, they agreed it was not useful to specify the exact composition of the team but agreed with previous NICE recommendations on essential core members.

How the recommendation might affect practice

The recommendation reflects general principles of care and is largely in line with current practice, so is not expected to have an impact on resources.

Return to recommendation