NICE is updating its guideline on the identification, assessment and management of overweight and obesity. Since the original recommendations were published in 2006 there is more evidence available on the best ‘follow up’ care for people who have undergone weight loss surgery and the role of surgery for people recently diagnosed with type 2 diabetes. There is also more information on the effectiveness and safety of very-low-calorie diets including how they should be managed and maintaining weight loss. 

Commenting on the new draft guidance Professor Mark Baker, Centre for Clinical Practice director, said: “Obesity rates have nearly doubled over the last 10 years and continue to rise, making obesity and overweight a major issue for the health service in the UK. NICE has already published a range of guidelines to help prevent and treat obesity; this draft guideline focusses on the clinical assessment and management. It clearly sets out what treatments should be offered to people with obesity and in what order. Since the publication of the existing guidance in 2006, more information has become available on how best to tackle the issue.

“Very-low-calorie diets have grown in popularity in recent years, so we now have more evidence to consider  how well they work, if the weight loss can be sustained and the safety concerns, than we did in 2006. The new draft guidance now recommends that they should not be used routinely for people who are obese, only those who have who have a clinical need to lose weight quickly, such as before joint replacement surgery.

“Updated evidence suggests people who are obese and have been recently diagnosed with type 2 diabetes may benefit from weight loss surgery. More than half of people who undergo surgery have more control over their diabetes following surgery and are less likely to have diabetes related illness; in some cases surgery can even reverse the diagnosis. The existing recommendations around weight loss surgery have not changed [1]”

The updated draft guideline will be available for consultation on the NICE website from Friday 11 July 2014. Draft recommendations include:

Bariatric surgery for people with recent onset type 2 diabetes:

• People who have recent onset type 2 diabetes and who are obese (BMI of 35 and over) should be offered an assessment for bariatric surgery.
• An assessment for bariatric surgery should be considered in people who have recent onset type 2 diabetes with a BMI of 30–34.9. If they are of Asian family origin consider an assessment at a lower BMI.

The point at which the level of body fat becomes risky to health varies between ethnic groups. Healthcare workers should apply lower thresholds to people from African, Caribbean, Asian and other minority ethnic groups than to those of European descent. Excess body fat contributes to more than half of cases of type 2 diabetes.

Very low calorie diets:

• Do not routinely use very-low-calorie diets (800 kcal/day or less) to manage obesity (defined as BMI over 30).
• Only consider very-low-calorie diets, with ongoing support, as part of a multicomponent weight management strategy for a maximum of 12 weeks (continuously or intermittently) in people who are obese who have a clinically-assessed need to rapidly lose weight (for example, people who require joint replacement surgery or who are seeking fertility services).
• Before starting someone on a very-low-calorie diet as part of a multi-component weight management strategy the person should be given counselling and assess for eating disorders or other psychopathology to make sure the diet is appropriate for them. The risks and benefits should be discussed and they should be told that very-low-calorie diets are not a long-term weight management strategy, and that regaining weight is likely and not because of their own or their clinician's failure.

Follow-up care:

• Offer people who have had bariatric surgery a follow-up care package for a minimum of 2 years within the bariatric service. This should include: nutritional monitoring; dietary and nutritional assessment, advice and support; physical activity advice and support; psychological support tailored to the individual; information about support groups.
• After discharge from bariatric surgery service follow up, ensure that all people are offered at least annual monitoring of nutritional status and appropriate supplementation according to need following bariatric surgery, as part of a shared care model of chronic disease management.

The public health aspects of NICE’s original obesity guideline are not addressed in this update, but some sections are in the process of being updated by the Centre for Public Health at NICE.

Ends

Notes to Editors

Explanation of terms

1. Obesity surgery (also known as bariatric surgery) includes gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. It is usually undertaken laparoscopically. The current NICE guideline recommends that surgery should be an option in certain circumstances.

The current guideline recommends that people with a BMI of 40 or more should be offered bariatric surgery, as long as they have tried and failed to achieve clinically beneficial weight loss by all other appropriate non-surgical methods and are fit for surgery. The evidence shows that bariatric surgery is both clinically and cost effective under these circumstances. This recommendation has not changed.

About the guidance

2. The draft guidance was published on Friday 11 July 2014. Final guidance is expected to be published in November.
3. Classification of obesity:

4. Obesity is directly linked to a number of different illnesses including type 2 diabetes, hypertension, gallstones and gastro oesophageal reflux disease, as well as psychological and psychiatric morbidities. The Health and Social Care Information Centre reported that in 2011/12 there were 11,740 inpatient admissions to hospitals in England with a primary diagnosis of obesity: 3 times as many as in 2006/07.