The papers chosen for inclusion were obtained and assessed for their methodological rigour against a number of criteria that determine the validity of the results. These criteria differed according to study type and were based on the checklists included in the National Institute for Clinical Excellence (NICE) Technical Manual, 'Guideline Development Methods - Information for National Collaborating Centres and Guideline Developers' (available from www.nice.org.uk and see also "Availability of Companion Documents" field in this summary). Critical appraisal was carried out by the systematic reviewers. Further appraisal was provided by the GDG members at and between the GDG meetings.

The data were extracted to standard evidence table templates. The findings were summarised by each systematic reviewer into a series of evidence statements and an accompanying narrative review. Where appropriate, a quantitative synthesis was conducted and checked by a consultant statistician.

Please refer to the full version of the original guideline document for "Review of the Public Health Evidence."

For each question, the highest level of evidence was selected. If a systematic review, meta-analysis or RCT existed in relation to the question being asked, studies of a weaker design were ignored. Where the evidence base was limited, questions were addressed by the identification of published expert narrative reviews by the project team and/or the GDG which formed the basis of discussion papers written either by the project lead or by a member of the GDG.

Additional Considerations for Clinical Management

Due to paucity of evidence for interventions in children, the GDG recommended that lower levels of evidence be considered throughout the reviews because of the limitations of the higher-level evidence available. Similarly in the reviews on surgical interventions for adults, longer-term case series (lower-level evidence) in addition to higher level RCTs were considered to provide the GDG with evidence on the long-term complications for each procedure.

Summary results and data are presented in the original full version guideline document. More detailed results and data are presented in the evidence tables in the original full version guideline document.

A number of key clinical questions could not appropriately be answered using a systematic review, for example, where the evidence base was very limited. These questions were addressed by the identification of 'published expert' narrative reviews by the project team and/or GDG which formed the basis of discussion papers written either by the project lead or the systematic reviewers.

This section should be read in conjunction with the National Institute for Health and Clinical Excellence (NICE) guideline on eating disorders (NICE clinical guideline no. 9; available from www.nice.org.uk/CG009), particularly if a person who is not overweight asks for advice on losing weight.

Adults and Children

After making an initial assessment (see specific recommendations below in this section under "Adults" and "Children"), healthcare professionals should use clinical judgement to investigate comorbidities and other factors in an appropriate level of detail, depending on the person, the timing of the assessment, the degree of overweight or obesity and the results of previous assessments.

Any comorbidities should be managed when they are identified, rather than waiting until the person has lost weight.

People who are not yet ready to change should be offered the chance to return for further consultations when they are ready to discuss their weight again and willing or able to make lifestyle changes. They should also be given information on the benefits of losing weight, healthy eating and increased physical activity.

Surprise, anger, denial or disbelief may diminish people's ability or willingness to change. Stressing that obesity is a clinical term with specific health implications, rather than a question of how you look, may help to mitigate this.

During the consultation it would be helpful to:

• Assess the person's view of their weight and the diagnosis, and possible reasons for weight gain
• Explore eating patterns and physical activity levels
• Explore any beliefs about eating and physical activity and weight gain that are unhelpful if the person wants to lose weight
• Be aware that people from certain ethnic and socioeconomic backgrounds may be at greater risk of obesity, and may have different beliefs about what is a healthy weight and different attitudes towards weight management
• Find out what the patient has already tried and how successful this has been, and what they learned from the experience
• Assess readiness to adopt changes
• Assess confidence in making changes

Patients and their families and/or carers should be given information on the reasons for tests, how the tests are performed and their results and meaning.

If necessary, another consultation should be offered to fully explore the options for treatment or discuss test results.

Adults

After appropriate measurements have been taken and the issues of weight raised with the person, an assessment should be done, covering:

• Presenting symptoms and underlying causes of overweight and obesity
• Eating behaviour
• Comorbidities (such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea) and risk factors, using the following tests – lipid profile, blood glucose (both preferably fasting) and blood pressure measurement
• Lifestyle – diet and physical activity
• Psychosocial distress and lifestyle, environmental, social and family factors – including family history of overweight and obesity and comorbidities
• Willingness and motivation to change
• Potential of weight loss to improve health
• Psychological problems
• Medical problems and medication

Referral to specialist care should be considered if:

• The underlying causes of overweight and obesity need to be assessed
• The person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care
• Conventional treatment has failed in primary or secondary care
• Drug therapy is being considered for a person with a BMI more than 50 kg/m²
• Specialist interventions (such as a very-low-calorie diet for extended periods) may be needed
• Surgery is being considered

Children

After measurements have been taken and the issue of weight raised with the child and family, an assessment should be done, covering:

• Presenting symptoms and underlying causes of overweight and obesity
• Willingness and motivation to change
• Comorbidities (such as hypertension, hyperinsulinaemia, dyslipidaemia, type 2 diabetes, psychosocial dysfunction and exacerbation of conditions such as asthma) and risk factors
• Psychosocial distress, such as low self-esteem, teasing and bullying
• Family history of overweight and obesity and comorbidities
• Lifestyle – diet and physical activity
• Environmental, social and family factors that may contribute to overweight and obesity and the success of treatment
• Growth and pubertal status

Referral to an appropriate specialist should be considered for children who are overweight or obese and have significant comorbidity or complex needs (for example, learning or educational difficulties).

In secondary care, the assessment of overweight and/or obese children and young people should include assessment of associated comorbidities and possible aetiology, and investigations such as:

• Blood pressure measurement
• Fasting lipid profile
• Fasting insulin and glucose levels
• Liver function
• Endocrine function

These tests need to be performed, and results interpreted, in the context of the degree of overweight and obesity, the child's age, history of comorbidities, possible genetic causes and any family history of metabolic disease related to overweight and obesity.

Arrangements for transitional care should be made for young people who are moving from paediatric to adult services.

Lifestyle Interventions

The recommendations in this section deal with lifestyle changes for people actively trying to lose weight; recommendations about lifestyle changes and self-management strategies for people wishing to maintain a healthy weight can be found in section 1.1.1 of the full version of the original guideline document.

General

Adults and Children

Multicomponent interventions are the treatment of choice. Weight management programmes should include behaviour change strategies (see recommendations below under "Behavioural Interventions") to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet and reduce energy intake.

When choosing treatments, the following factors should be considered:

• The person's individual preference and social circumstance and the experience and outcome of previous treatments (including whether there were any barriers)
• Their level of risk, based on BMI and waist circumference (see recommendations above, under "Classification of Overweight and Obesity")
• Any comorbidities

The results of the discussion should be documented, and a copy of the agreed goals and actions should be kept by the person and the healthcare professional or put in the notes as appropriate. Healthcare professionals should tailor support to meet the person's needs over the long term.

The level of support offered should be determined by the person's needs, and be responsive to changes over time.

Any healthcare professional involved in the delivery of interventions for weight management should have relevant competencies and have undergone specific training.

Information should be provided in formats and languages that are suited to the person. When talking to patients and carers, healthcare professionals should use everyday, jargon-free language and explain any technical terms. Consideration should be given to the person's:

• Age and stage of life
• Gender
• Cultural needs and sensitivities
• Ethnicity
• Social and economic circumstances
• Physical and mental disabilities

To encourage the patient through the difficult process of changing established behaviour, healthcare professionals should praise successes – however small – at every opportunity.

People who are overweight or obese, and their families and/or carers, should be given relevant information on:

• Overweight and obesity in general, including related health risks
• Realistic targets for weight loss; for adults the targets are usually
  • Maximum weekly weight loss of 0.5–1 kg*
  • Aim to lose 5–10% of original weight
• The distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; the change from losing weight to maintenance typically happens after 6–9 months of treatment
• Realistic targets for outcomes other than weight loss, such as increased physical activity, healthier eating
• Diagnosis and treatment options
• Healthy eating in general (see appendix D in the full version of the original guideline document)
• Medication and side effects
• Surgical treatments

• Self care
• Voluntary organisations and support groups and how to contact them

*Based on the British Dietetic Association 'Weight Wise' Campaign. Greater rates of weight loss may be appropriate in some cases, but this should be undertaken only under expert supervision.

There should be adequate time in the consultation to provide information and answer questions.

If a person (or their family or carers) does not want to do anything at this time, healthcare professionals should explain that advice and support will be available in the future whenever they need it. Contact details should be provided, so that the person can make contact when they are ready.

Adults

The person's partner or spouse should be encouraged to support any weight management programme.

The level of intensity of the intervention should be based on the level of risk and the potential to gain health benefits (see recommendation above, under "Classification of Overweight and Obesity").

Children

Single-strategy approaches to managing weight are not recommended for children or young people.

The aim of weight management programmes for children and young people may be either weight maintenance or weight loss, depending on their age and stage of growth.

Parents of overweight or obese children and young people should be encouraged to lose weight if they are also overweight or obese.

Behavioural Interventions

Adults and Children

Any behavioural intervention should be delivered with the support of an appropriately trained professional.

Adults

Behavioural interventions for adults should include the following strategies, as appropriate for the person:

• Self monitoring of behaviour and progress
• Stimulus control
• Goal setting
• Slowing rate of eating
• Ensuring social support
• Problem solving
• Assertiveness
• Cognitive restructuring (modifying thoughts)
• Reinforcement of changes
• Relapse prevention
• Strategies for dealing with weight regain

Children

Behavioural interventions for children should include the following strategies, as appropriate for the child:

• Stimulus control
• Self monitoring
• Goal setting
• Rewards for reaching goals
• Problem solving

Although not strictly defined as behavioural techniques, giving praise and encouraging parents to role-model desired behaviours are also recommended.

Physical Activity

Adults

Adults should be encouraged to increase their physical activity even if they do not lose weight as a result, because of the other health benefits physical activity can bring, such as reduced risk of type 2 diabetes and cardiovascular disease. Adults should be encouraged to do at least 30 minutes of at least moderate-intensity physical activity on 5 or more days a week. The activity can be in one session or several lasting 10 minutes or more.

To prevent obesity, most people should be advised they may need to do 45–60 minutes of moderate-intensity activity a day, particularly if they do not reduce their energy intake. People who have been obese and have lost weight should be advised they may need to do 60–90 minutes of activity a day to avoid regaining weight.

Adults should be encouraged to build up to the recommended levels for weight maintenance, using a managed approach with agreed goals.

Recommended types of physical activity include:

• Activities that can be incorporated into everyday life, such as brisk walking, gardening or cycling
• Supervised exercise programmes
• Other activities, such as swimming, aiming to walk a certain number of steps each day, or stair climbing

Any activity should take into account the person's current physical fitness and ability.

People should also be encouraged to reduce the amount of time they spend inactive, such as watching television or using a computer.

Children

Children and young people should be encouraged to increase their physical activity even if they do not lose weight as a result, because of the other health benefits exercise can bring, such as reduced risk of type 2 diabetes and cardiovascular disease. Children should be encouraged to do at least 60 minutes of at least moderate activity each day. The activity can be in one session or several lasting 10 minutes or more.

Children who are already overweight may need to do more than 60 minutes' activity.

Children should be encouraged to reduce sedentary behaviours, such as sitting watching television, using a computer or playing video games.

Children should be given the opportunity and support to do more exercise in their daily lives (such as walking, cycling, using the stairs and active play). The choice of activity should be made with the child, and be appropriate to their ability and confidence.

Children should be given the opportunity and support to do more regular, structured physical activity, such as football, swimming or dancing. The choice of activity should be made with the child, and be appropriate to their ability and confidence.

Dietary Advice

Adults and Children

Dietary changes should be individualised, tailored to food preferences and allow for flexible approaches to reducing calorie intake.

Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful.

People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits.

Adults

The main requirement of a dietary approach to weight loss is that total energy intake should be less than energy expenditure.

Diets that have a 600 kcal/day deficit (that is, they contain 600 kcal less than the person needs to stay the same weight) or that reduce calories by lowering the fat content (low-fat diets), in combination with expert support and intensive follow-up, are recommended for sustainable weight loss.

Low-calorie diets (1000–1600 kcal/day) may also be considered, but are less likely to be nutritionally complete.

Very-low-calorie diets (less than 1000 kcal/day) may be used for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), by people who are obese and have reached a plateau in weight loss.

Any diet of less than 600 kcal/day should be used only under clinical supervision.

In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.

Children

A dietary approach alone is not recommended. It is essential that any dietary recommendations are part of a multicomponent intervention.

Any dietary changes should be age appropriate and consistent with healthy eating advice.

For overweight and obese children and adolescents, total energy intake should be below their energy expenditure. Changes should be sustainable.

Pharmacological Interventions

This section contains recommendations that update the NICE technology appraisals on orlistat and sibutramine (NICE technology appraisal guidance no. 22 and NICE technology appraisal guidance no. 31); see section 6 of the full length original guideline document for details.

General: Indications and Initiation

Adults and Children

Pharmacological treatment should be considered only after dietary, exercise and behavioural approaches have been started and evaluated.

Adults

Drug treatment should be considered for patients who have not reached their target weight loss or have reached a plateau on dietary, activity and behavioural changes alone.

The decision to start drug treatment, and the choice of drug, should be made after discussing with the patient the potential benefits and limitations, including the mode of action, adverse effects and monitoring requirements, and their potential impact on the patient's motivation. When drug treatment is prescribed, arrangements should be made for appropriate healthcare professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies. Information on patient support programmes should also be provided.

Prescribing should be in accordance with the drug's summary of product characteristics.

Children

Drug treatment is not generally recommended for children younger than 12 years.

In children younger than 12 years, drug treatment may be used only in exceptional circumstances, if severe life-threatening comorbidities (such as sleep apnoea or raised intracranial pressure) are present. Prescribing should be started and monitored only in specialist paediatric settings. (At the time of publication [December 2006], orlistat and sibutramine do not have UK marketing authorisation for use in children. Prescribers should be aware of the special considerations and issues when prescribing for children.)

In children aged 12 years and older, treatment with orlistat or sibutramine is recommended only if physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities are present. Treatment should be started in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group.

Orlistat or sibutramine should be prescribed for obesity in children only by a multidisciplinary team with expertise in:

• Drug monitoring
• Psychological support
• Behavioural interventions
• Interventions to increase physical activity
• Interventions to improve diet

Orlistat and sibutramine should be prescribed for young people only if the prescriber is willing to submit data to the proposed national registry on the use of these drugs in young people (see also Section 8 of the full length original guideline document).

After drug treatment has been started in specialist care, it may be continued in primary care if local circumstances and/or licensing allow.

Continued Prescribing and Withdrawal

Adults and Children

Pharmacological treatment may be used to maintain weight loss, rather than continue to lose weight.

If there is concern about the adequacy of micronutrient intake, a supplement providing the reference nutrient intake for all vitamins and minerals should be considered, particularly for vulnerable groups such as older people (who may be at risk of malnutrition) and young people (who need vitamins and minerals for growth and development).

People whose drug treatment is being withdrawn should be offered support to help maintain weight loss, because their self-confidence and belief in their ability to make changes may be low if they did not reach their target weight.

Adults

Regular review is recommended to monitor the effect of drug treatment and to reinforce lifestyle advice and adherence.

Withdrawal of drug treatment should be considered in people who do not lose enough weight (see specific recommendations under "Orlistat" and "Sibutramine" below).

Rates of weight loss may be slower in people with type 2 diabetes, so less strict goals than those for people without diabetes may be appropriate. These goals should be agreed with the person and reviewed regularly.

Children

If orlistat or sibutramine is prescribed for children, a 6–12-month trial is recommended, with regular review to assess effectiveness, adverse effects and adherence.

Orlistat

Adults

Orlistat should be prescribed only as part of an overall plan for managing obesity in adults who meet one of the following criteria:

• A BMI of 28.0 kg/m² or more with associated risk factors
• A BMI of 30.0 kg/m² or more

Therapy should be continued beyond 3 months only if the person has lost at least 5% of their initial body weight since starting drug treatment. (See also recommendation above for advice on targets for people with type 2 diabetes.)

The decision to use drug treatment for longer than 12 months (usually for weight maintenance) should be made after discussing potential benefits and limitations with the patient.

The coprescribing of orlistat with other drugs aimed at weight reduction is not recommended.

Sibutramine

Adults

Sibutramine should be prescribed only as part of an overall plan for managing obesity in adults who meet one of the following criteria:

• A BMI of 27.0 kg/m² or more and other obesity-related risk factors such as type 2 diabetes or dyslipidaemia
• A BMI of 30.0 kg/m² or more

Sibutramine should not be prescribed unless there are adequate arrangements for monitoring both weight loss and adverse effects (specifically pulse and blood pressure).

Therapy should be continued beyond 3 months only if the person has lost at least 5% of their initial body weight since starting drug treatment. (See also recommendation above for advice on targets for people with type 2 diabetes.)

Treatment is not currently recommended beyond the licensed duration of 12 months.

The coprescribing of sibutramine with other drugs aimed at weight reduction is not recommended.

Surgical Interventions

This section updates the NICE technology appraisal on surgery for people with morbid obesity (NICE technology appraisal guidance no. 46); see section 6 of the full length original guideline document for details.

Adults and Children

Bariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled:

• They have a BMI of 40 kg/m² or more, or between 35 kg/m² and 40 kg/m² and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
• 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 person has been receiving or will receive intensive management in a specialist obesity service
• The person is generally fit for anaesthesia and surgery
• The person commits to the need for long-term follow-up

See recommendations below for additional criteria to use when assessing children and adults.

Severely obese people who are considering surgery to aid weight reduction (and their families as appropriate) should discuss in detail with the clinician responsible for their treatment (that is, the hospital specialist and/or bariatric surgeon) the potential benefits and longer-term implications of surgery, as well as the associated risks, including complications and perioperative mortality.

The choice of surgical intervention should be made jointly by the person and the clinician, and taking into account:

• The degree of obesity
• Comorbidities
• The best available evidence on effectiveness and long-term effects
• The facilities and equipment available
• The experience of the surgeon who would perform the operation

Regular, specialist postoperative dietetic monitoring should be provided, and should include:

• Information on the appropriate diet for the bariatric procedure
• Monitoring of the person's micronutrient status
• Information on patient support groups
• Individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance

Arrangements for prospective audit should be made, so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.

The surgeon in the multidisciplinary team should:

• Have undertaken a relevant supervised training programme
• Have specialist experience in bariatric surgery
• Be willing to submit data for a national clinical audit scheme

Adults

In addition to the criteria listed in recommendation 1.2.6.1 of the full length original guideline document, bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m² in whom surgical intervention is considered appropriate.

In people for whom surgery is recommended as a first-line option, orlistat or sibutramine can be used to maintain or reduce weight before surgery if it is considered that the waiting time for surgery is excessive.

Surgery for obesity should be undertaken only by a multidisciplinary team that can provide:

• Preoperative assessment, including a risk–benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s)
• Providing information on the different procedures, including potential weight loss and associated risks
• Regular postoperative assessment, including specialist dietetic and surgical follow-up
• Management of comorbidities
• Psychological support before and after surgery
• Providing information on, or access to, plastic surgery (such as apronectomy) where appropriate
• Access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for patients undergoing bariatric surgery, and staff trained to use them

Surgery should be undertaken only after a comprehensive preoperative assessment of any psychological or clinical factors that may affect adherence to postoperative care requirements, such as changes to diet.

Revisional surgery (if the original operation has failed) should be undertaken only in specialist centres by surgeons with extensive experience because of the high rate of complications and increased mortality.

Children

Surgical intervention is not generally recommended in children or young people.

Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity.

Surgery for obesity should be undertaken only by a multidisciplinary team that can provide paediatric expertise in:

• Preoperative assessment, including a risk–benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s)
• Information on the different procedures, including potential weight loss and associated risks
• Regular postoperative assessment, including specialist dietetic and surgical follow-up
• Management of comorbidities
• Psychological support before and after surgery
• Information on or access to plastic surgery (such as apronectomy) where appropriate
• Access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for patients undergoing bariatric surgery, and staff trained to use them

Surgical care and follow-up should be coordinated around the young person and their family's needs and should comply with national core standards as defined in the Children's NSFs for England and Wales.

All young people should have had a comprehensive psychological, education, family and social assessment before undergoing bariatric surgery.

A full medical evaluation including genetic screening or assessment should be made before surgery to exclude rare, treatable causes of the obesity.

National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (listed below). These are available on their website (http://www.nice.org.uk/CG043 [see also the "Availability of Companion Documents field"]).

• Slides highlighting key messages for local discussion.
• Costing tools
  • Costing report to estimate the national savings and costs associated with implementation.
  • Costing template to estimate the local costs and savings involved.
• A signposting document on how to put the guidance into practice and national initiatives that support this locally.
• Audit criteria to monitor local practice.

Other Audiences and Settings

The guidance also makes recommendations for the following audiences and settings:

• Public bodies – including local authorities; government, government agencies and arm's length bodies; schools, colleges and childcare in early years settings; forces, prisons and police service
• Private and voluntary organisations
  • Large employers (more than 250 employees)
  • Small and medium employers (less than 50 and less than 250 employees, respectively)
• The general public including parents, and the media and others providing advice for different population groups

Key Priorities for Implementation

• The prevention and management of obesity should be a priority for all, because of the considerable health benefits of maintaining a healthy weight and the health risks associated with overweight and obesity.

Public Health

NHS

• Managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority, at both strategic and delivery levels. Dedicated resources should be allocated for action.

Local Authorities and Partners

• Local authorities should work with local partners, such as industry and voluntary organisations, to create and manage more safe spaces for incidental and planned physical activity, addressing as a priority any concerns about safety, crime and inclusion, by:
  • Providing facilities and schemes such as cycling and walking routes, cycle parking, area maps and safe play areas
  • Making streets cleaner and safer, through measures such as traffic calming, congestion charging, pedestrian crossings, cycle routes, lighting and walking schemes
  • Ensuring buildings and spaces are designed to encourage people to be more physically active (for example, through positioning and signing of stairs, entrances and walkways)
  • Considering in particular people who require tailored information and support, especially inactive, vulnerable groups

Early Years Settings

• Nurseries and other childcare facilities should:
  • Minimise sedentary activities during play time, and provide regular opportunities for enjoyable active play and structured physical activity sessions
  • Implement Department for Education and Skills, Food Standards Agency and Caroline Walker Trust guidance on food procurement and healthy catering.

Schools

• Head teachers and chairs of governors, in collaboration with parents and pupils, should assess the whole school environment and ensure that the ethos of all school policies helps children and young people to maintain a healthy weight, eat a healthy diet and be physically active, in line with existing standards and guidance. This includes policies relating to building layout and recreational spaces, catering (including vending machines) and the food and drink children bring into school, the taught curriculum (including PE), school travel plans and provision for cycling, and policies relating to the National Healthy Schools Programme and extended schools.

Workplaces

• Workplaces should provide opportunities for staff to eat a healthy diet and be physically active, through:
  • Active and continuous promotion of healthy choices in restaurants, hospitality, vending machines and shops for staff and clients, in line with existing Food Standards Agency guidance
  • Working practices and policies, such as active travel policies for staff and visitors
  • A supportive physical environment, such as improvements to stairwells and providing showers and secure cycle parking
  • Recreational opportunities, such as supporting out-of-hours social activities, lunchtime walks and use of local leisure facilities.

Self-help, Commercial and Community Settings

• Primary care organisations and local authorities should recommend to patients, or consider endorsing, self-help, commercial and community weight management programmes only if they follow best practice (see recommendation 1.1.7.1 in the original full guideline document for details of best practice standards).

Clinical Care

Children and Adults

• Multicomponent interventions are the treatment of choice. Weight management programmes should include behaviour change strategies to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet and reduce energy intake.

Children

• Interventions for childhood overweight and obesity should address lifestyle within the family and in social settings.
• Body mass index (BMI) (adjusted for age and gender) is recommended as a practical estimate of overweight in children and young people, but needs to be interpreted with caution because it is not a direct measure of adiposity.
• Referral to an appropriate specialist should be considered for children who are overweight or obese and have significant comorbidity or complex needs (for example, learning or educational difficulties).

Adults

• The decision to start drug treatment, and the choice of drug, should be made after discussing with the patient the potential benefits and limitations, including the mode of action, adverse effects and monitoring requirements and their potential impact on the patient's motivation. When drug treatment is prescribed, arrangements should be made for appropriate health professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies. Information about patient support programmes should also be provided.
• Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled:
  • They have a BMI of 40 kg/m² or more, or between 35 kg/m² and 40 kg/m² and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.
  • 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 person has been receiving or will receive intensive management in a specialist obesity service.
  • The person is generally fit for anaesthesia and surgery.
  • The person commits to the need for long-term follow-up.
• Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m² in whom surgical intervention is considered appropriate.

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site.

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. 11 Strand, London, WC2N 5HR.

• Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children NICE guideline (Clinical guideline 43). London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Dec. 84 p. Electronic copies: Available in Portable Document Format (PDF) and Microsoft (MS) Word Format from the National Institute for Health and Clinical Excellence (NICE) Web site.
• Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Quick reference guide 1: for local authorities, schools and early years providers, workplaces and the public. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Dec. 15 p. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.
• Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Quick reference guide 2 for NHS. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Dec. 27 p. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.
• Obesity. Guide to resources to support implementation. 2006 Dec. 18 p. Electronic copies: Available in Microsoft (MS) Word format from the NICE Web site.
• Obesity. Costing report. Implementing NICE guidance in England. 2006 Dec. 39 p. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.
• Obesity. Costing template. Implementing NICE guidance in England. 2007 Feb. Various p. Electronic copies: Available in Microsoft (MS) Excel Format from the NICE Web site.
• Obesity. Audit criteria. 2006 Dec. 21 p. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.
• Obesity. Presenter slides. Implementing NICE guidance. 2006 Dec. 45 p. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.
• The guidelines manual 2006. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Apr. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site.

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. 11 Strand, London, WC2N 5HR.

• Treatment for people who are overweight or obese. Understanding NICE guidance. Information for people who use NHS and social care services. National Institute for Health and Clinical Excellence (NICE), 2006 Dec. (amended July 2008). 12 p. Available in Portable Document Format (PDF) and in Microsoft (MS) Word Format from the National Institute for Health and Clinical Excellence (NICE) Web site.
• Preventing obesity and staying a healthy weight. Understanding NICE guidance. Information for the public. National Institute for Health and Clinical Excellence (NICE), 2006 Dec. (amended July 2008) 7 p. Available in Portable Document Format (PDF) and in Microsoft (MS) Word Format from the NICE Web site.

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. ref: N1145. 11 Strand, London, WC2N 5HR.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.