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Obesity Implementing NICE guidance. updated March 2010. NICE clinical guideline 43. Sibutramine. Sibutramine (Reductil): marketing authorisation suspended

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Obesity

Implementing NICE guidance

updated March 2010

NICE clinical guideline 43


Sibutramine
Sibutramine

  • Sibutramine (Reductil): marketing authorisation suspended

  • On 21 January 2010, the MHRA announced the suspension of the marketing authorisation for the obesity drug sibutramine (Reductil). This follows a review by the European Medicines Agency which found that the cardiovascular risks of sibutramine outweigh its benefits. Emerging evidence suggests that there is an increased risk of non-fatal heart attacks and strokes with this medicine.


What this presentation covers
What this presentation covers:

  • background

  • the guidance

  • key recommendations for prevention

  • key recommendations for assessment and

  • management

  • costs and savings

  • tools that can help


Background changing practice
Background: changing practice

  • NICE guidance is based on the best available evidence.

  • The Department of Health asks NHS organisations to work towards implementing NICE guidance, and compliance is monitored by the Care Qaulity Commission.

  • Other organisations will want to use the guidance to implement best practice.


Who the guidance is aimed at
Who the guidance is aimed at

  • local authorities and partners in the community

  • early years providers

  • schools

  • workplaces

  • self-help, commercial and community programmes

  • the public

  • the NHS


Need for this guidance
Need for this guidance

  • Rising prevalence of obesity in England

  • Over 50% of all adults are overweight or obese

  • Estimated current cost of obesity and overweight is between £6.6 and £7.4 billion annually


Associated comorbidities
Associated comorbidities

  • Adults

  • type 2 diabetes

  • coronary heart disease (CHD)

  • hypertension

  • various cancers

  • osteoarthritis

  • Children and teenagers

  • hypertension

  • hyperinsulinaemia

  • dyslipidaemia

  • type 2 diabetes

  • psychosocial dysfunction

  • exacerbation of existing conditions

  • orthopaedic problems


What the guidance covers
What the guidance covers

Prevention of overweight and obesity in adults and children

Identification and assessment

Management of overweight and obesity in adults

and children:

  • lifestyle changes

  • drug treatment

  • surgery


Prevention and management of obesity is a priority for all
Prevention and management of obesity is a priority for all

  • Ensure that preventing and managing obesity is a priority, at both strategic and delivery levels

  • Dedicate resources for action and training


Key recommendations for local authorities
Key recommendations for local authorities

  • Work with local partners to create and manage more safe spaces for incidental and planned physical activity

  • Address as a priority any concerns around safety, crime and inclusion

  • Provide facilities and schemes such as cycling and walking routes, cycle parking, area maps and safe play areas

  • Make streets cleaner and safer, through measures such as traffic calming, congestion charging, pedestrian crossings, cycle routes, lighting and walking schemes


Recommended actions for local authorities
Recommended actions for local authorities

  • All relevant workplace policies should support the local obesity strategy

  • Work with the local community to identify environmental barriers to eating healthily and being physically active

  • Ensure building designs encourage the use of stairs and walkways

  • Encourage local shops and caterers to promote healthy food and drink choices


Key recommendations for early years settings
Key recommendations for early years settings

Minimise sedentary activities during play time

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 (see

www.cwt.org.uk) guidance on food procurement and

healthy catering

Involve parents and carers


Key recommendations for schools
Key recommendations for schools

  • Head teachers and chairs of governors, in collaboration with parents and pupils, should:

    • assess the whole school environment

    • ensure school policies help children to eat a

      healthy diet, be physically active and maintain a

      healthy weight

    • use a whole-school approach to develop life-long

      healthy eating and physical activity

      practices


Recommended actions for schools
Recommended actions for schools

  • Ensure school policies and the school’s environment encourage physical activity and a healthy diet

  • Teaching, support and catering staff should have training on how to implement healthy school policies

  • Establish links with health professionals


Key recommendation for self help commercial and community settings
Key recommendation forself-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


Principles of best practice
Principles of best practice

  • Endorse programmes only if they meet best practice standards by:

    • helping people decide on a realistic healthy target weight

    • focusing on long-term lifestyle changes

    • addressing both diet and activity, and offering a variety of approaches

    • using a balanced, healthy-eating approach

    • offering practical, safe advice about being more active

    • including some behaviour-change techniques

    • recommending and/or providing ongoing support


Key recommendations for workplaces
Key recommendations for workplaces

  • Ensure policies encourage activity and healthy eating

  • Provide opportunities for staff to eat a healthy diet through promotion of healthy choices in restaurants, hospitality, vending machines and shops, in line with Food Standards Agency guidance


Key recommendations for workplaces1
Key recommendations for workplaces

  • Provide opportunities for staff to be physically active through:

    • 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


Key recommendations for the nhs
Key recommendations for the 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

  • dedicate resources for action and training

  • consider endorsing, self-help, commercial and community weight management programmes

  • if they follow best practice


Recommended actions for the nhs as an employer
Recommended actions for the NHS as an employer

  • Ensure policies encourage activity and healthy eating among staff

  • Provide showers and secure cycle parking to encourage active travel

  • Actively promote healthy choices in restaurants

  • Improve stairwells to encourage use of stairs


Recommended actions for all health professionals
Recommended actions for allhealth professionals

  • Offer tailored advice based on individual preferences and needs

  • Involve parents and carers in actions aimed at children and young adults

  • Discuss weight, diet and activity at times when weight gain is more likely

  • Focus interventions on activities that fit easily into everyday life

  • Use multicomponent interventions


Recommended actions for health professionals in community settings
Recommended actions for health professionals in community settings

  • Support and promote healthy eating and physical activity through retail and catering schemes, schemes and facilities to encourage physical activity, and behavioural change programmes

  • Support implementation of workplace programmes on obesity

  • In community programmes, address local concerns, including the availability of services, cost and safety


Recommended actions for health professionals in early years settings
Recommended actions for health professionals in settingsearly years settings

  • Use a range of components (not just parental education):

    • offer interactive cookery and physical activity demonstrations

    • use videos and discussions on meal planning and shopping

    • provide opportunities for active play


Clinical recommendations for the nhs
Clinical recommendations settingsfor the NHS

Identification and assessment

Management of overweight and obesity in adults and children:

  • lifestyle changes

  • drug treatment

  • surgery


Assessment and management: settingsadults

Determine degree of

overweight or obesity

Consider referral

to specialist care

Assess lifestyle,

comorbidities and

willingness to change

Specialist assessment

and management;

surgery and follow up

Management:

lifestyle changes;

drug treatment


Determine degree of overweight or obesity adults
Determine degree of settingsoverweight or obesity: adults


Assess lifestyle comorbidities and willingness to change adults
Assess lifestyle, comorbidities and willingness to change: adults

Including:

  • presenting symptoms and underlying causes

    of overweight or obesity

  • willingness to change

  • risk factors and comorbidities

  • eating behaviour

  • lifestyle – diet and physical activity

  • psychosocial factors


Management lifestyle changes for adults
Management: lifestyle changes for adults adults

  • Offer multicomponent interventions, including behaviour change strategies to encourage:

    • increased physical activity

    • improved eating behaviour

    • healthy eating


Behavioural change strategies adults
Behavioural change adultsstrategies: adults

  • self monitoring of behaviour and progress

  • stimulus control

  • goal setting

  • slowing rate of eating

  • ensuring social support


Behavioural change strategies adults1
Behavioural change adultsstrategies: adults

  • problem solving

  • assertiveness

  • cognitive restructuring (modifying thoughts)

  • reinforcement of changes

  • relapse prevention

  • strategies for dealing with weight regain


Referral to specialist care adults
Referral to specialist care: adults adults

Consider referral to specialist care if:

  • underlying causes of overweight and obesity need to be assessed

  • there are complex disease states and/or needs that cannot be managed adequately in primary or secondary care

  • conventional treatment has failed

  • specialist interventions may be needed

  • drug therapy is being considered for a person with a BMI of 50 kg/m2 or more

  • surgery is being considered


Management drug treatment for adults
Management: drug treatment for adults adults

  • Drug treatment should be considered for adults:

    • only after dietary and exercise advice have

    • been started and evaluated

    • for patients who have not reached their

    • target weight or have reached a plateau

  • These recommendations update the NICE

  • technology appraisal on orlistat


Surgical treatment adults
Surgical treatment: adults adults

  • Consider surgery if allof the following conditions

  • are met:

    • the person has a BMI of 40 kg/m² or more, OR

    • a BMI of 35 to 40 kg/m² plus other significant

    • disease that could be improved with weight loss

    • non-surgical measures have failed to achieve or

    • maintain clinically beneficial weight loss for at

    • least 6 months

    • the person has been receiving or will receive

    • intensive management in a specialist obesity

    • service, such as psychologicalsupport


Assessment and management: children and young people adults

Determine degree of

overweight or obesity

Consider referral

to an appropriate

specialist

Consider intervention

or assessment

Assessment in

secondary care

Assess lifestyle,

comorbidities and

willingness to change

Specialist

management:

drug treatment;

surgery

Management:

lifestyle changes


Determine degree of overweight or obesity children and young people
Determine degree of overweight or obesity: children and young people

  • Use clinical judgement to decide when to

    measure height and weight

  • Use BMI – UK 1990 BMI charts

  • Discuss with child/young person and their family

  • Use clinical judgement to decide when to

  • measure height and weight

  • Use BMI – UK 1990 BMI charts

  • Discuss with child/young person and their family

  • Use clinical judgement to decide when to

  • measure height and weight

  • Use BMI – UK 1990 BMI charts

  • Discuss with child/young person and their family

  • Use clinical judgement to decide when to

  • measure height and weight

  • Use the UK 1990 BMI charts

  • Discuss with child/young person and their family



Assess lifestyle comorbidities and willingness to change children
Assess lifestyle, comorbidities and willingness to change: children

Including:

  • presenting symptoms and underlying causes

    of overweight or obesity,

  • willingness to change

  • risk factors and comorbidities

  • eating behaviours

  • lifestyle – diet and physical activity

  • psychosocial factors


Management lifestyle changes for children
Management: lifestyle changes for children children

  • Offer multicomponent interventions that include behaviour change strategies to:

    • increase physical activity levels or decrease

      inactivity

    • improve eating behaviour or quality of diet


Behavioural change strategies children
Behavioural change childrenstrategies: children

  • stimulus control

  • self monitoring

  • goal setting

  • rewards for reaching goals

  • problem solving

  • Giving praise and encouraging parents to role-model desired behaviours are also recommended


  • Referral to specialist care children
    Referral to specialist care: children children

    Consider referral to specialist care if the child has:

    • significant comorbidity or

    • complex needs – such as learning or educational difficulties


    Management drug treatment for children
    Management: childrendrug treatment for children

    Consider drug treatment only if multicomponent dietary,

    exercise and behavioural approaches have been started

    and evaluated.

    Children under 12: drug treatment not generally recommended.

    Prescribe only in exceptional circumstances such as severe

    life-threatening comorbiditiesChildren over 12: drug treatment is recommended only if

    there are severe comorbidities

    Prescribing should be started by a specialist multidisciplinary

    team with experience of prescribing for this age group


    Surgical treatment young people
    Surgical treatment: childrenyoung people

    Surgery is not generally recommended

    for children or young people.

    However, in exceptional circumstances

    it may be considered for young people.


    Costs
    Costs children


    Savings
    Savings children


    Access tools online
    Access tools online children

    • Costing tools

      • costing report

      • costing template

    • Guide to useful resources

    • Audit criteria

    • Available from: www.nice.org.uk/CG043


    Access the guidance online
    Access the guidance online children

    • Twoquick reference guides –www.nice.org.uk/CG043quickrefguide

    • NICE guideline – all of the recommendations www.nice.org.uk/CG043niceguideline

    • Full guideline – all of the evidence and rationale www.nice.org.uk/CG043fullguideline

    • Two ‘Understanding NICE guidance’ booklets– plain English versions www.nice.org.uk/CG043publicinfo


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