Managing overweight and obesity among children and young people: lifestyle weight management services Issued: October 2013 NICE public health guidance 47 guidance.nice.org.uk/ph47 NICE has accredited the process used by the Centre for Public Health Excellence at NICE to produce guidance. Accreditation is valid for 5 years from January 2010 and applies to guidance produced since April 2009 using the processes described in NICE's 'Methods for the development of NICE public health guidance' (2009). More information on accreditation can be viewed at www.nice.org.uk/ accreditation © NICE 2013 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Contents Introduction: scope and purpose of this guidance...................................................................... 7 What is this guidance about?................................................................................................................ 7 Who is this guidance for? ..................................................................................................................... 8 1 Recommendations ................................................................................................................. 9 Background........................................................................................................................................... 9 Principles of weight management for children and young people......................................................... 9 Lifestyle weight management programmes ......................................................................................... 10 Whose health will benefit? ................................................................................................................... 10 Recommendation 1 Planning lifestyle weight management services for children and young people... 10 Recommendation 2 Commissioning lifestyle weight management programmes for children and young people......................................................................................................................................... 11 Recommendation 3 Lifestyle weight management programmes: core components............................. 13 Recommendation 4 Developing a tailored plan to meet individual needs ............................................ 15 Recommendation 5 Encouraging adherence to lifestyle weight management programmes................ 17 Recommendation 6 Raising awareness of lifestyle weight management programmes: commissioners and programme providers ........................................................................................... 18 Recommendation 7 Raising awareness of lifestyle weight management programmes: health professionals, other professionals and voluntary organisations ........................................................... 19 Recommendation 8 Formal referrals to lifestyle weight management programmes ............................ 20 Recommendation 9 Providing ongoing support: health professionals ................................................. 22 Recommendation 10 Providing ongoing support: lifestyle weight management programmes ............. 23 Recommendation 11 Lifestyle weight management programme staff: training .................................... 23 Recommendation 12 Lifestyle weight management programme staff: knowledge and skills .............. 24 Recommendation 13 Training in how to make referrals to a lifestyle weight management programme ........................................................................................................................................... 25 Recommendation 14 Supporting lifestyle weight management programme staff and those making programme referrals.............................................................................................................................. 26 Recommendation 15 Monitoring and evaluating programmes ............................................................. 27 © NICE 2013. All rights reserved. Last modified October 2013 Page 2 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 2 Public health need and practice.............................................................................................. 29 Obesity and overweight statistics.......................................................................................................... 29 Childhood obesity and health................................................................................................................ 29 Weight management programmes........................................................................................................ 30 Financial consequences of childhood obesity....................................................................................... 31 3 Considerations ........................................................................................................................ 32 Introduction............................................................................................................................................ 32 The evidence......................................................................................................................................... 32 Family-based approach......................................................................................................................... 33 Tailoring programmes ........................................................................................................................... 34 Determining whether a child is overweight or obese............................................................................. 35 Referring on to specialist services ....................................................................................................... 35 Children and young people with special needs .................................................................................... 36 Encouraging adherence to programmes .............................................................................................. 36 Behaviour-change techniques .............................................................................................................. 37 Increasing uptake of programmes......................................................................................................... 38 Training and support............................................................................................................................. 38 Sustaining behaviour changes ............................................................................................................. 39 Monitoring, evaluation and setting outcome measures ........................................................................ 39 Economic considerations...................................................................................................................... 41 4 Recommendations for research.............................................................................................. 43 Recommendation 1 Research studies and trials................................................................................... 43 Recommendation 2 Longer-term programme evaluation...................................................................... 44 Recommendation 3 Barriers and facilitators ........................................................................................ 44 Recommendation 4 Weight management programmes........................................................................ 45 5 Related NICE guidance........................................................................................................... 47 Published .............................................................................................................................................. 47 © NICE 2013. All rights reserved. Last modified October 2013 Page 3 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Under development............................................................................................................................... 47 6 Glossary ................................................................................................................................. 48 Behaviour-change techniques............................................................................................................... 48 BMI z score .......................................................................................................................................... 48 Body mass index (BMI)......................................................................................................................... 48 Child and adolescent mental health services (CAMHS) ....................................................................... 49 Clinical commissioning groups ............................................................................................................. 49 Comorbidities ....................................................................................................................................... 49 Complex obesity ................................................................................................................................... 49 Evaluation ............................................................................................................................................. 49 Health and wellbeing boards................................................................................................................. 50 Joint strategic needs assessments (JSNAs)......................................................................................... 50 Lifestyle weight management programmes ......................................................................................... 50 Lifestyle weight management services ................................................................................................ 50 Local authority commissioners ............................................................................................................. 50 Monitoring ............................................................................................................................................. 51 National Child Measurement Programme............................................................................................. 51 NHS England ........................................................................................................................................ 51 Obesity care or weight management pathway...................................................................................... 51 Physical activity..................................................................................................................................... 51 Positive parenting skills training............................................................................................................ 52 Providers of lifestyle weight management programmes ....................................................................... 52 Public Health England........................................................................................................................... 52 Rolling programmes ............................................................................................................................. 52 Sedentary behaviour............................................................................................................................. 52 Specialist obesity services ................................................................................................................... 53 Stimulus control..................................................................................................................................... 53 © NICE 2013. All rights reserved. Last modified October 2013 Page 4 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Universal obesity prevention services .................................................................................................. 53 UK 1990 centile charts ......................................................................................................................... 53 7 References.............................................................................................................................. 54 8 Summary of the methods used to develop this guidance........................................................ 56 Introduction............................................................................................................................................ 56 Guidance development......................................................................................................................... 56 Key questions........................................................................................................................................ 56 Reviewing the evidence ....................................................................................................................... 58 Commissioned report ........................................................................................................................... 61 Cost effectiveness................................................................................................................................. 61 How the PDG formulated the recommendations................................................................................... 61 9 The evidence .......................................................................................................................... 63 Evidence statements............................................................................................................................. 64 Economic modelling .............................................................................................................................106 10 Gaps in the evidence.............................................................................................................108 11 Membership of the Programme Development Group (PDG) and the NICE project team ....110 Programme Development Group.......................................................................................................... 110 NICE project team................................................................................................................................. 112 12 About this guidance............................................................................................................... 114 Why has guidance been produced?...................................................................................................... 114 How was this guidance developed?...................................................................................................... 114 What evidence is the guidance based on? ........................................................................................... 114 Status of this guidance.......................................................................................................................... 116 Implementation...................................................................................................................................... 116 Updating the recommendations ........................................................................................................... 116 Your responsibility................................................................................................................................. 117 © NICE 2013. All rights reserved. Last modified October 2013 Page 5 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Copyright............................................................................................................................................... 117 © NICE 2013. All rights reserved. Last modified October 2013 Page 6 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Introduction: scope and purpose of this guidance What is this guidance about? This guidance aims to provide recommendations on lifestyle weight management services for overweight and obese children and young people. The recommendations cover: planning services commissioning programmes core components of lifestyle weight management programmes developing a tailored programme plan to meet individual needs encouraging adherence raising awareness of programmes formal referrals to programmes providing ongoing support programme staff: training, knowledge and skills training in how to make programme referrals supporting programme staff and those making programme referrals monitoring and evaluating programmes. This guidance does not cover services that focus on preventing obesity (sometimes called universal obesity prevention services or tier 1 services), specialist obesity services (sometimes called tier 3 services) or the use of pharmacological or surgical treatments for obesity (sometimes called tier 4 services). In addition, it does not make recommendations for adults. (See Related NICE guidance for other recommendations that may be relevant to managing obesity among adults, children and young people.) See About this guidance for details of how the guidance was developed and its current status. © NICE 2013. All rights reserved. Last modified October 2013 Page 7 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 Who is this guidance for? The recommendations are for commissioners in local authorities and the NHS and providers of community-based services that take a 'lifestyle' approach to helping overweight or obese children and young people manage their weight. They are also for health professionals and people working with children and young people. Although local terminology varies, these are sometimes called tier 2 services and are just 1 part of a comprehensive approach to preventing and treating obesity. The guidance may also be of interest to children and young people, their parents, carers, families and other members of the public. The guidance complements but does not replace NICE guidance on obesity, body mass index and waist circumference among minority ethnic groups, how local communities can prevent obesity, physical activity for children and young people, and weight management in pregnancy. (For further details, see Related NICE guidance.) © NICE 2013. All rights reserved. Last modified October 2013 Page 8 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 1 Recommendations Background The Programme Development Group (PDG) considers that the recommendations are likely to be cost effective. The evidence underpinning the recommendations is listed in The evidence. See also Supporting evidence for the evidence reviews, economic modelling report, expert papers and commissioned report. For the research recommendations see Recommendations for research and Gaps in the evidence respectively. The recommendations in this guidance cover lifestyle weight management services for overweight and obese children and young people aged under 18. However, no evidence was identified about the effectiveness of such programmes specifically aimed at children under 6. The absence of such programmes from the recommendations is a result of this lack of evidence and should not be taken as a judgement on whether or not they are effective and cost effective. Principles of weight management for children and young people Assessing the body mass index (BMI) of children is more complicated than for adults because it changes as they grow and mature. In addition, growth patterns differ between boys and girls. Thresholds that take into account a child's age and sex are used to assess whether their BMI is too high or too low. These are usually derived from a reference population, known as a child growth reference, with the data presented in BMI centile charts. In a clinical assessment, a child or young person on or above the 98th centile is classified as obese. A child or young person on or above the 91st centile, but below the 98th centile, is classified as overweight[1]. When monitoring and comparing groups of children and young people BMI z scores may be used. These are a measure of how many standard deviations a child or young person's BMI is above or below the average BMI for their age and gender. © NICE 2013. All rights reserved. Last modified October 2013 Page 9 of 117 Managing overweight and obesity among children and young NICE public health people: lifestyle weight management services guidance 47 In this guidance, the term BMI centile is used in recommendations that focus on working with individual children or young people. 'BMI z score' is used in recommendations relating to monitoring and research. Further information can be found in A simple guide to classifying body mass index in children. Lifestyle weight management programmes Many lifestyle weight management programmes aim to maintain the growing child's existing weight in the short term, as they grow taller. This is an appropriate short-term aim, because it will result in an improved BMI over time, and is often described as 'growing into their weight'. Young people who are overweight or obese and are no longer growing taller will ultimately need to lose weight to improve their BMI. However, preventing further weight gain while they gain the knowledge and skills they need to make lifestyle changes, may be an appropriate short-term aim. These changes then need to become firmly established habits over the long term. Whose health will benefit? Children and young people who are overweight or obese. Recommendation 1 Planning lifestyle weight management services for children and young people Who should take action? Directors of public health and public health teams working on obesity and child health and wellbeing. Health and wellbeing boards. Local authority commissioners. Clinical commissioning groups. NHS England. © NICE 2013. All rights reserved. Last modified October 2013 Page 10 of 117