T here is increasing recognition, both in the UK and worldwide, that there is 'an obesity epidemic', which is currently becoming one of the major challenges to public health. This is supported by research evidence based on analyses of national surveys over the past 20 years.1 Around two-thirds of men and women, approximately 24 million adults, were either overweight or obese in 2004. Furthermore, 0.9% of men and 2.6% of women can be classified as morbidly obese with a body mass index (BMI) of over 40 kg/m2.1 Changes in lifestyle, work, leisure, and eating habits have all contributed to this situation. The rising prevalence of obesity indicates that action hitherto has been insufficient.
This short article only covers a few illustrative points, but, hopefully, it will encourage all in the primary care sector to see this as a priority area, and to refer to the much more detailed recommendations in the new NICE guideline.2
Why is the integrated guidance needed?
This is the first national guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children in England and Wales.2 The guideline aims to:
- stem the rising prevalence of obesity, and diseases associated with it
- increase the effectiveness of interventions to prevent overweight and obesity
- improve the care provided to obese adults and children, particularly in the primary care sector.
As will be seen from the research evidence and the guideline recommendations, essentially similar approaches are required for prevention and management. Likewise, with respect to those who provide care and advice, there is no rigid division between those from a clinical or health background and those from other disciplines working in the community. Public health and clinical audiences share the same need for evidence-based, cost-effective solutions in their day-to-day work, and to inform policies and strategies to improve health.
The aim of the guideline is to support and enable healthcare workers and other professionals to take full advantage of the opportunities to improve health. It also is intended to provide information for the public to ensure that there can be an agreed plan of action.3
Evidence base of the guideline
The fairly limited research evidence base, particularly with respect to children and young people, and in relation to preventive strategies, is disappointing. Many studies were very limited with respect to their research design, follow-up, study population, and setting. Some of the areas looked at, such as community-based interventions and exercise programmes, are not accustomed to the rigour of the clinical trial.
The recommendations on research in the guideline argue in favour of more UK studies being based in normal service settings. They suggest that there should be a standard approach to outcome measures, economic evaluation, study design, and follow-up, in order to accumulate meaningful data for formulation of future policy.4 There is also a need to strengthen the evidence of what works, in both prevention and treatment.
An initial search of research publications for the two guideline groups, clinical and public health, yielded a consistency of approach, for example with respect to multicomponent intervention, which helped to strengthen our recommendations. It was, again, disappointing to see such a number of small projects that had looked promising but were not evaluated, and so were unable to contribute in the longer term.
The primary care setting
The primary care setting was a major focus of concern in the guideline, which recognised the need for a practical approach to cover both prevention and care.
In view of the number of people in the population that might require care, the limited resources available and, in some cases, the lack of appropriate training for personnel, there is a risk that the recommendations in the NICE guideline might be seen as encouraging the public and patients to 'overuse' services. However, many of these people will be in contact with health professionals anyway, and the recommendations should result in more appropriate care at an early stage.
It is not only aimed at healthcare professionals, but also at those working in various settings in the community—leisure, activity, sports, and education.
Many people who are obese, with conditions such as heart disease, will already be seeing their GP or practice nursing staff. Others will be attending the practice intermittently, which provides the possibility of opportunistic enquiry and advice, where this is appropriate.
The main message for clinical care is clear: multicomponent interventions are the treatment of choice, and a dietary approach alone is not recommended. Weight management programmes should include behavioural change strategies to increase the patient's level of physical activity, improve eating behaviour and the quality of the diet, and reduce energy intake.
People need to be made aware that intermittent 'crash' diets seldom halt the usual progressive weight increase.
Dietary changes and exercise, supported by behavioural changes, should be the first-line treatment for adults who are overweight or obese. This should be followed by drug treatment if lifestyle interventions are unsuccessful or have reached a plateau.
It is intended that the recommendations should apply to all healthcare professionals and the broad definition allows for both scope of action and involvement of all the professional skills. This includes GPs, nurses, public health practitioners, behavioural psychologists, physiotherapists, pharmacists — and suitably trained pharmacy staff, who may offer advice and support — trained counsellors, registered dieticians, public health nutritionists, and specifically trained exercise specialists. Advice on maintaining a healthy weight includes:2
- making a physical activity such as walking, cycling, swimming, aerobics, or gardening a part of everyday life
- eating five portions of fruit and vegetables a day
- avoiding foods that are high in fat and sugar.
Obesity in children
Although there are close parallels between children and adults, as is indicated in the published clinical pathways, there are important differences. Interventions for childhood overweight and obesity should address lifestyle within the family and social settings.
Referral to an appropriate specialist should be considered for children who are overweight or obese and have significant co-morbidity or complex needs. While BMI, adjusted for age and gender, is advised as a practical estimate of recommended weight, it needs to be interpreted with caution because it is not a direct measure of adiposity.
Drug treatment for obesity
In adults, the decision to start drug treatment, and the choice of drug, should be made after discussing the potential benefits and limitations with the patient. When drug treatment is prescribed, arrangements should be made for appropriate health professionals to offer information, support, and counselling on additional dietary, and behavioural strategies, including physical activity. Drug treatment should be considered only after these other approaches have been started and evaluated.
There is need for regular review, and drug treatment may be used to maintain weight loss as well as to continue to lose weight. Consideration should be given to withdrawing drug treatment if the patient does not lose enough weight.
There has been considerable media interest regarding the recommendations on bariatric surgery, and primary care professionals are likely to be asked about it. In adults, it is recommended if all the following criteria are fulfilled:2
- a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease that could be improved by weight reduction
- as a first-line option for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate
- all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
- the patient has been receiving or will receive intensive management in a specialist obesity service, is generally fit for anaesthesia and surgery, and commits to the need for long-term follow up.
Surgery is not generally recommended for children and young people. For those who have achieved or nearly achieved physiological maturity it may be considered in exceptional circumstances, which are detailed in the guideline.2
In producing recommendations, the guideline has sought to be sufficiently flexible to take account of personal lifestyle and circumstances. It aims to ensure that there is recognition of clinical judgement, as well as the necessity for an agreed approach by the individual, or the family, in the case of children. There is no single or simple approach that will be effective in the treatment of overweight and obesity, and, therefore, a broad and comprehensive view is required for action to improve the public health.
The foreword to the guideline notes, 'We have sought to produce guidance that will build on the existing services, recognising that further training and staff will be required. The report aims to be ambitious and forward looking. To do otherwise would have been irresponsible with a major health priority, which is continuing to increase in prevalence.' 4
NICE implementation tools
NICE has developed the following tools to support implementation of its guideline on the management of overweight and obesity in adults and children. They are now available to download from the NICE website: www.nice.org.uk.
Guide to resources to support implementation
- Investment in obesity services is likely to produce long-term but not immediate savings against the indicative budget
- Most obesity management can and should be provided in primary care
- Key tariff prices:1
- medical outpatients = £200 (new), £94 (follow-up)
- one year´s weight-reducing medication ≈ £400
- Investment in a local nurse-led weight management service is likely to ensure elements of the budget spent on drugs and surgery are made when indicated as per NICE guidance and not inappropriately
- If diabetes can be prevented, many costs will be avoided, especially in prescribing costs and primary care nursing time
- Department of Health. Health Survey for England 2004. London: DH, 2005.
- National Institute for Health and Care Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline No 43. London: NICE, 2006.
- National Institute for Health and Care Excellence. Understanding NICE guidance: Information for people who use NHS services. Treatment for people who are overweight or obese. London: NICE, 2006.
- National Institute for Health and Care Excellence and the National Collaborating Centre for Primary Care. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. London: NICE and the National Collaborating Centre for Primary Care, 2006.G