Professor Julian Hamilton-Shield explains the thinking behind the recent NICE quality standard on prevention and lifestyle weight management in children and young people with obesity
Read this article to learn more about:
- the prevalence of obesity in children and young people in England
- how NICE Quality Standard 94 will help the NHS, commissioners, local communities, and families to support obesity prevention in children.
Childhood obesity continues to be a major cause for concern in England. Health Survey for England data for 2012 suggest a prevalence of obesity in young people aged 11–15 years of 18.7%.1
Recent data from primary care electronic healthcare records suggest that the extra-ordinary increases of 8% per year for the prevalence of childhood obesity seen in the 1990s is abating, with much smaller annual increases in the last decade of about 0.4%.2 The fact that around 1 in 5 young adolescents in England is obese, however, remains a major issue for future NHS resources.
NICE Quality Standard 94
In response to continuing concerns about preventing and treating childhood obesity, NICE published Quality Standard (QS) 94 on Obesity in children and young people: prevention and lifestyle weight management programmes in July 2015.3 Its seven quality statements (see Table 1, Below) were developed primarily from NICE Public Health (PH) Guideline 47 (2014) on Weight management: lifestyle services for overweight or obese children and young people.4 The following additional material was also considered:
- Obesity: working with local communities—NICE PH42 (2012).5
- Type 2 diabetes prevention: population and community-level interventions—NICE Ph25 (2011)6
- Obesity prevention—NICE Clinical Guideline 43 (2006).7
|1||Children and young people, and their parents or carers, using vending machines in local authority and NHS venues can buy healthy food and drink options.|
|2||Children and young people, and their parents or carers, see details of nutritional information on menus at local authority and NHS venues.|
|3||Children and young people, and their parents or carers, see healthy food and drink choices displayed prominently in local authority and NHS venues.|
|4||Children and young people, and their parents or carers, have access to a publicly available up-to-date list of local lifestyle weight management programmes.|
|5||Children and young people identified as being overweight or obese, and their parents or carers as appropriate, are given information about local lifestyle weight management programmes.|
|6||Family members or carers of children and young people are invited to attend lifestyle weight management programmes, regardless of their weight.|
|7||Children and young people, and their parents or carers, can access data on attendance, outcomes and the views of participants and staff from lifestyle weight management programmes.|
|8||Reducing sedentary behaviour
This placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.
NICE (2012). QS94. Obesity in children and young people: prevention and lifestyle weight management programmes. Available at: www.nice.org.uk/guidance/qs94
The aims of NICE QS94 are to address both the universal prevention of overweight and obesity in children and young people (Tier 1), and lifestyle weight management interventions in Tier 1 and 2 (community) settings. The ultimate goals are for improved outcomes in:3
- excess weight in children and young people aged under 18 years
- children and young people's dietary behaviours
- the amount of time children and young people spend inactive
- prevalence of type 2 diabetes in children and young people
- children's self-esteem and mental health wellbeing
- use of child and adolescent mental health services (CAMHS).
Healthy food and drink options in vending machines—statement 1
It is undoubtedly the case that dietary habits are a significant contributor to the excess weight seen in both children and adults. Any cursory review of vending machine items for purchase in many hospitals and other local authority venues reveals a less than satisfactory spectrum of food choices, with the majority of items being confectionary, sugar-fortified drinks, and very few items of fresh produce. Such an environment for buying food is likely to be very obesogenic.
Statement 1 is in line with the successful Healthy Hospitals Initiative launched in the USA in 20128 which has led to major improvements in the quality of beverages purchased, and in other areas suggesting improved dietary indices in those hospitals taking part.9 By improving the so-termed 'consumer nutrition environment', you allow people to make healthier food choices more easily.
A useful tool that could be adapted for use in the UK is the US Hospital Nutrition Environment Scan (HNES) for cafeterias, vending machines, and gift shops,10 allowing audit of this quality statement.
Nutritional information at the point of choosing food and drink options—statement 2
This quality statement requires that, in venues supplying food that children may access, all facilities within the NHS and local authorities display nutritional content information. This includes not only calorie content but also levels of fat, saturated fat, salt, and sugar.3 Furthermore, this information should be available in an accessible format for the target audience.
In the author's professional opinion the information should also be interpreted meaningfully and appropriately for the target audience with special attention paid to the changing dietary needs of children. This is important, as nutrient requirements, especially daily recommended calories, change across childhood; few parents are likely to have an in-depth knowledge of recommended daily allowances for any of these constituents for adults, let alone for how they vary across childhood. So there will need to be significant dietetic input into the information sheets provided to inform consumers about healthy choices.
Prominent placement of healthy options—statement 3
A study from Canada in 2007 found that less than 1% of product placements aimed at children in supermarkets were for fruit and vegetables, whereas 89% could be classified as being of 'poor nutritional quality'.11 So-called 'child pester power' is a well-acknowledged, major influence on parental buying decisions.12
To facilitate the purchase of healthy foods in hospital and local authority venues, healthy food options, rather than the typical confectionary and high-sugar beverages, should be placed prominently at a child's eye level.
Maintaining details of local lifestyle weight management programmes—statement 4
It is important that relevant information on current opportunities for accessing weight management interventions for families who are concerned about their child's weight are widely available and accessible. Increased public awareness of these programmes may lead to more self-referrals, either by children and young people themselves or their parents or carers.
All professionals working with children should be aware of these opportunities, of how recruitment is undertaken, and be able to help families to access them easily. An increased awareness among healthcare professionals may lead to more direct referrals.
Raising awareness of lifestyle weight management programmes—statement 5
This statement has implications for:
- providers of weight management interventions who need to maintain a dialogue with local authorities and NHS services regarding the availability of programmes, entry criteria, localities, and how to access them
- healthcare professionals, most importantly, GPs and those who run the National Child Measurement Programme (NCMP)
- commissioners, who must ensure that healthcare providers and other professionals working with children take the opportunity, when a problem is identified, to signpost families to the services provided locally.
Implicit in the statement regarding the second of these groups is that GPs should know which of their patients might have need of such services. Recent research has shown that the vast majority of children on general practice lists do not have a recent body mass index (BMI) recorded in their notes.13
Furthermore, NCMP data are not routinely fed back to the child's primary care team and so an opportunity to identify and take action with families who might benefit from primary care referral to weight management programmes is currently missed.13 In addition, statement 5 implies that NCMP staff should use the data they have on children to signpost families to weight management interventions when information on the child's weight, at around ages 5 and 11 years, is fed back to parents.
Family involvement in lifestyle weight management programmes—statement 6
This quality statement relates directly to evidence that weight management interventions are more effective when they involve the whole family in adjusting lifestyle behaviours than when a child's weight problem is addressed in isolation.14 Family involvement in weight management programmes is likely to benefit the whole family's health and offers encouragement and support to the child whose weight problem first brought the family to the intervention.
Evaluating lifestyle weight management programmes—statement 7
For families considering engaging in weight management interventions, it is important that they understand not only the implications for personal and family commitment but also the likelihood of a successful outcome in terms of change in lifestyle behaviours and BMI. Until now, most community-based weight management intervention programmes have been poorly evaluated, if at all.15
This quality statement includes a number of key process and outcome data that should be collected and analysed with regard to recruitment, retention, accessibility, and weight improvement (measured as a BMI z score). Furthermore, the statement emphasises the need to collect qualitative experiences from families attending, and from staff providing the programme.
Providers of weight management interventions will need to be far more pro-active in collecting the relevant data, which will need to be open to scrutiny by commissioners when re-commissioning or adjusting service provision in the future. It would be invaluable if all such data were posted on a website such as Public Health England's Collection of resources on evaluation.16 This would facilitate comparison between services when future commissioning is being considered.
NICE quality standards are designed to drive measurable improvements in patient experience and outcome. Although NICE is in no position to influence consumer (and child) exposure to product placement in the commercial world, the first three quality statements in QS94 aim to set standards by which the NHS and local authority venues can help families to make improved food and drink choices when on their premises. If only through example, such steps should be of benefit in reducing the burden of childhood obesity. Statements 4 and 5 relate to improving both public and professional awareness of weight management interventions that are provided locally. These statements also endorse the signposting of people identified as having weight problems to appropriate services by healthcare professionals. Inviting and involving the whole family in the behaviour change programme is encouraged in statement 6. The final statement emphasises the importance of services collecting robust data on accessibility, retention, and outcomes in terms of weight change, behaviour change, and patient experience; these outcomes should be easily open to scrutiny from commissioners.
The seven quality statements in NICE QS94 will not in themselves solve the childhood obesity problem in England; they will, however, provide the NHS and local authorities with important measurable, attainable steps and so support children and families in achieving healthier lifestyles and weight levels.
This is an independent opinion from a Biomedical Research Unit in the National Institute for Health Research Biomedical Research Centre and Unit Funding Scheme. The views expressed in this publication are those of the author and not necessarily those of the NHS, NICE, the National Institute for Health Research, or the Department of Health.
- Statement 1 and 3: In both NHS and LA venues: percentage of healthy drinks purchased compared with total. Percentage reduction, year-on-year, of the number of confectionary items purchased.
- Statement 2: Percentage of food choices offered on menus at NHS and LA authority venues that have calorie, salt, sugar and fat content described for each item.
- Statement 4: Percentage of currently available services that LAs can demonstrate are on a publicly accessible website with effective signposting in NHS and LA venues, including schools and primary care sites.
- Statement 5: Percentage of children identified as overweight and obese in National Child Measurement Programme who are signposted to currently available services.
- Statement 6: Percentage of children who attend interventions with at least one parent/carer present.
- Statement 7: LAs have a publicly accessible website with outcomes of interventions detailed (such as average BMI changes and retention) and vignettes of patient and staff experiences.
LA=local authority; BMI=body mass index
GP commissioning messages
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- The prime responsibility for implementing and commissioning services to support this quality standard lies with local departments of public health in local authorities:
- unfortunately, public health budgets are being cut and this will produce challenges for investment in local services to help overweight children
- Local authorities will need to work with NHS England and CCGs, who increasingly co-commission GP services, to identify what actions they require from local GP practices; they will then commission specific services where appropriate
- A precise strategy for addressing the problems of childhood obesity should be agreed between all commissioners and included in local joint strategic needs assessments and health and wellbeing plans
- There may be increased opportunities for a joined-up approach to addressing childhood obesity under local devolution proposals (e.g. the devolution agreement between the Government and Greater Manchester, 'Devo-Manc'), when fragmented commissioning arrangements and budgets can be brought together to implement the Health and Wellbeing Plan.
- The prevalence of obesity in children and young people in England continues to be of great concern:
- NICE Quality Standard 94 aims to address this issue through prevention and lifestyle weight management measures at population and family-based levels
- Healthy food and drink options should be available from all vending machines on NHS and local authority premises
- Outlets providing food and drink on NHS and local authority premises should:
- give nutritional information about products
- make it easier for children and families to make healthier choices
- Children and young people should have access to information about weight management interventions available for them in their area:
- professionals offering weight management interventions for families need to keep local authorities and NHS services informed about their services, so that information is up to date
- health professionals should inform the families of children and young people who have been identified as being obese, about these interventions
- Family members, regardless of their weight, should be encouraged to join in with their obese child (or children) at weight management interventions
- Families need to access participant feedback and information about outcomes to assess how successful any intervention is likely to be for them.
- Public Health England. Data factsheet: child weight. PHE, 2014. Available at: www.noo.org.uk/securefiles/151210_1423//Child_weight_factsheet_October_2015.pdf↩
- van Jaarsveld C, Gulliford M. Childhood obesity trends from primary care electronic health records in England between 1994 and 2013: population-based cohort study. Arch Dis Child 2015; 100 (3): 214–219. ↩
- NICE. Obesity in children and young people: prevention and lifestyle weight management programmes. Quality Standard 94. NICE, 2015. Available at: www.nice.org.uk/guidance/qs94↩
- NICE. Weight management: lifestyle services for overweight or obese children and young people. Public Health Guidance 47. NICE, 2013. Available at: www.nice.org.uk/guidance/ph47↩
- NICE. Obesity: working with local communities. Public Health Guidance 42. NICE, 2012. Available at: www.nice.org.uk/guidance/ph42↩
- NICE. Type 2 diabetes prevention: population and community-level interventions. Public Health Guidance 35. NICE, 2011. Available at: www.nice.org.uk/guidance/ph35↩
- NICE. Obesity prevention. Clinical Guideline 43. NICE, 2006. Available at: www.nice.org.uk/guidance/cg43↩
- American Hospital Association Long-Range Policy Committee. A call to action: creating a culture of health. Chicago: AHA, 2011. Available at: www.aha.org/research/cor/content/creating-a-culture-of-health.pdf↩
- Healthier Hospitals. 2014 milestone report. Healthier Hospitals, 2014. Available at: healthierhospitals.org/sites/default/files/IMCE/fnl_hhi_milestone_report_061015_lores.pdf↩
- Winston C, Sallis J, Swartz M et al. Reliability of the Hospital Nutrition Environment Scan for cafeterias, vending machines, and gift shops. J Acad Nutr Diet 2013; 113 (8): 1069–1075. ↩
- Elliott C. Assessing 'fun foods': nutritional content and analysis of supermarket foods targeted at children. Obesity Rev 2008; 9 (4): 368–377. ↩
- Campbell S, James E, Stacey F et al. A mixed-method examination of food marketing directed towards children in Australian supermarkets. Health Promot Int 2014; 29 (2) :267–277. ↩
- Banks J, Shield J, Sharp D. Barriers engaging families and GPs in childhood weight management strategies. Br J Gen Pract 2011; 61 (589): e492–497. ↩
- Morgan F, Weightman A, Whitehead S, Brophy S. Managing overweight and obesity among children and young people: lifestyle weight management services. Review 1: Effectiveness and cost effectiveness of lifestyle weight management services for children and young people. Available at: www.nice.org.uk/guidance/ph47/evidence/review-of-effectiveness-and-cost-effectiveness-430360093 (accessed 5 October 2015). ↩
- Aicken C, Roberts H, Arai L. Mapping service activity: the example of childhood obesity schemes in England. BMC Public Health 2010; 10: 310–315. ↩
- Public Health England Obesity website. Collection of Resources on Evaluation—CoRE. www.noo.org.uk/core (accessed 4 October 2015). ↩G