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.

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?

What action should they take?

Recommendation 2 Commissioning lifestyle weight management programmes for children and young people

Who should take action?

What action should they take?

  • Identify needs using the joint strategic needs assessment. Use community engagement techniques with local families to identify any barriers and facilitators discouraging or encouraging the uptake and completion of programmes.

  • Commission lifestyle weight management services to meet the needs of local children and young people, including those of different ages, different stages of development and from different cultural backgrounds. Services should be in line with the health and wellbeing strategy.

  • Consider how best to provide services for overweight or obese children and young people with special needs or disabilities. For example, through specific programmes where these are available. Or by making reasonable adaptations to mainstream programmes (including training staff) and evaluating them. Ensure there is an appropriate interface with specialist obesity services to help those with more complex needs manage their weight.

  • Ensure all lifestyle weight management programmes are designed and developed with input from a multidisciplinary team and have taken into account the views of children, young people and their families. The team should include professionals who specialise in children, young people and weight management. These include the following:

    • a state registered dietitian or registered nutritionist

    • a physical activity specialist

    • a behaviour-change expert, such as a health promotion specialist (for physical activity, a sport and exercise psychologist may be appropriate)

    • a health or clinical psychologist, or a child or adolescent psychiatrist, to provide expertise in mental wellbeing

    • a paediatrician or paediatric nurse.

  • Ensure programme content is regularly reviewed and updated by the multidisciplinary team.

  • Ensure providers can demonstrate that staff are trained to deliver the specific programme commissioned and are experienced in working with children, young people and their families.

  • Ensure sufficient resources are dedicated to monitoring and evaluation.

  • Ensure there are clearly defined programme objectives, outputs, outcomes and monitoring and evaluation requirements in programme specifications and in contracts. Contracts should also specify any at-risk groups that should be targeted, such as black and minority ethnic groups, or children and young people from low income families or neighbourhoods.

  • Ensure key performance indicators are agreed with programme providers, including the proportion of sessions that must be attended to complete the programme (see recommendation 15).

  • Ensure the contract or programme specification requires that height and weight are measured and that both BMI and BMI for age and gender (BMI z score) are recorded. All children and young people should be measured at the following times:

    • at recruitment to the programme

    • at completion of the programme

    • 6 months after completing the programme

    • 1 year after completing the programme.

For recommendations for providers see recommendations 3, 5, 10 and 14.

See also recommendation 10 in Obesity: working with local communities (NICE public health guidance 42).

Recommendation 3 Lifestyle weight management programmes: core components

What action should they take?

  • Ensure all lifestyle weight management programmes for overweight and obese children and young people are multi-component. They should focus on:

    • diet and healthy eating habits

    • physical activity

    • reducing the amount of time spent being sedentary

    • strategies for changing the behaviour of the child or young person and all close family members.

  • Ensure the following core components, developed with the input of a multidisciplinary team (see recommendation 2) are included:

    • Behaviour-change techniques to increase motivation and confidence in the ability to change. This includes strategies to help the family identify how changes can be implemented and sustained at home.

    • Positive parenting skills training, including problem-solving skills, to support changes in behaviour.

    • An emphasis on the importance of encouraging all family members to eat healthily and to be physically active, regardless of their weight.

    • A tailored plan to meet individual needs, appropriate to the child or young person's age, gender, ethnicity, cultural background, economic and family circumstances, any special needs and how obese or overweight they are. This should include helping them and their family to set goals, monitor progress against them and provide feedback (see recommendation 4).

    • Information and help to master skills in, for example, how to interpret nutritional labelling and how to modify culturally appropriate recipes on a budget.

    • Help to identify opportunities to become less sedentary and to build physical activity into their daily life (for example, by walking to school and through active play).

    • A range of physical activities (such as games, dancing and aerobics) that the children or young people enjoy and that can help them gradually become more active.

    • Information for family members who may not attend the programme itself to explain the programme's aims and objectives and how they can provide support.

    • Ongoing support and follow-up for participants who have completed the programme.

Recommendation 4 Developing a tailored plan to meet individual needs

What action should they take?

  • Assess each child or young person for obesity-associated diseases or conditions (comorbidities). Use a locally approved comorbidities assessment tool, where available. Assessment is particularly important if the child or young person and their family have self-referred to the programme, or have not been assessed by a health professional. Refer them to their GP if any concerns are identified.

  • Identify whether the child or young person's mental wellbeing is affected by their weight. For example, whether there are any signs of psychological distress, depression, bulimia, self-harming or other mental health problems related to their weight.

  • Identify whether their weight is a consequence of circumstances that have affected their mental wellbeing. (For example, if they have experienced bereavement or have caring responsibilities.)

  • If concerns about their mental wellbeing are identified refer the child or young person to their GP for assessment and treatment and, if appropriate, for onward referral to child and adolescent mental health services (CAMHS). (Note: such concerns may be identified at any stage of a weight management programme.)

  • Take account of the child or young person's self-esteem, self-perception and any previous attempts to manage their weight. Provide opportunities, in either a group or one-to-one session, for them to talk about any victimisation or distress if they wish. (This includes any history of bullying or teasing.)

  • Find out whether the family recognises that their child is overweight or obese and the potential benefits of managing their weight. Discuss the family's history of attempts to manage their weight, and their existing knowledge of, and attitudes towards, food, physical activity and the amount of time spent being sedentary.

  • Weigh, measure, determine and record the child or young person's BMI. Offer to do the same for parents, carers and other family members. Measurements should be undertaken by staff who have been trained using standard protocols (see recommendation 11).

  • They should use validated, transportable instruments that are regularly calibrated.

  • Emphasise that the programme may benefit the whole family. In addition, offer information about local lifestyle weight management services to adult family members who are overweight or obese.

  • Encourage children and young people from around the age of 12 (depending on their ability and stage of development) to monitor their eating, physical activity and any sedentary behaviour. For example, encourage them to keep a record of time spent watching television or playing computer games, and what they snack on and when, to identify areas that need addressing. For younger children, parents and carers should monitor these behaviours, with the involvement of the child according to their age and stage of development.

  • Work with children from around the age of 12 (depending on their ability and stage of development) to identify situations in which it would be possible for them to eat more healthily or to become less sedentary and more active. For example, this might involve gradually reducing TV viewing at certain times and replacing this with more active pastimes. Work with the parents and carers of younger children to achieve the same.

  • Aim to gradually increase the amount of moderate to vigorous-intensity physical activity programme participants do every day. Focus on activities they enjoy and that are easily accessible. This includes activities that can be built into daily life, such as active play, walking or cycling. Aim to achieve the age-specific UK physical activity guidelines.

  • Agree dietary changes that are age-appropriate, affordable, culturally sensitive and consistent with healthy eating advice. Ensure nutrient needs for growth and development are met by including healthier choices, in appropriate amounts, from each of the food groups (see NHS Choices Eatwell plate). Changes to diet should take into account the child or young person's likes and dislikes.

  • Manage expectations of what can be realistically achieved over the duration of the programme. Small but realistic goals should be mutually agreed with the child or young person and their family. These should relate to goals that they value and that motivate them to attend.

  • Work with participants and their families to regularly monitor progress against the goals and provide feedback. Praise progress and achievements and update the goals as the child or young person progresses through the programme. If they do not meet their goals, discuss the possible causes for this and modify them if necessary.

  • Stress the importance of maintaining changes, no matter how small, over the longer term. Encourage participants to take up offers of ongoing support (see recommendation 10).

Recommendation 5 Encouraging adherence to lifestyle weight management programmes

What action should they take?

  • Offer programmes to groups of children or young people and their families. Where necessary, offer programmes to individual families, if this better meets their needs and preferences. For example, some families may prefer to attend individual sessions initially and attend group sessions as their confidence and self-esteem grows.

  • Offer a range of programmes for children and young people of different ages and at different stages of development. If group sessions are offered, work with groups of peers and their parents or carers. Note, some adolescents may respond better to programmes if their sessions are separate from those for their parents and carers.

  • Offer programmes in venues that have the necessary facilities, are easily accessible and where the child or young person and their family feel comfortable. For example, use local community venues that have space for physical activities or games, and that can be reached quickly and easily by walking, cycling or using public transport.

  • Offer programmes at a range of times that are convenient for families with children of different ages and for working parents and carers. For example, some sessions could be offered in the evenings or at weekends.

  • Adopt a flexible approach so that participants can accommodate other commitments. They may also prefer to attend programmes more frequently initially and less frequently as their skills and confidence in making changes grows. For example, use rolling programmes that allow participants to start at different points and cover the same material but not necessarily in the same order.

  • Emphasise the importance of parental (or carer) support and their commitment to adhere to the programme. Stress that this support and commitment should extend beyond the duration of the programme itself and that outcomes will be reviewed for at least the first year after completion.

  • Maintain regular contact with participants. Promptly follow up those who miss sessions to establish why and to restore commitment. Focus on participants from disadvantaged groups and those who miss sessions early on in the programme.

  • Try to retain the same team of staff throughout each cycle of the programme.

Recommendation 6 Raising awareness of lifestyle weight management programmes: commissioners and programme providers

Who should take action?

What action should they take?

  • Local authorities should ensure an up-to-date list of local lifestyle weight management programmes for children and young people is maintained. This should form part of a list of services commissioned for the local obesity care or weight management pathway. It should be regularly disseminated, or accessible to organisations in the public, community and voluntary sectors.

  • Use children's centres, libraries, the local media, professional and voluntary organisations working with children and young people and schools to raise awareness of lifestyle weight management programmes. Any publicity should clearly describe:

    • who the programme is for (age range, any eligibility criteria and the level of parental involvement needed)

    • how to enrol (including whether participants can self-refer or need a formal referral from a health professional)

    • programme aims

    • type of activities involved (to alleviate any anxieties about the unknown and to ensure expectations are realistic): 'healthy living' and any fun aspects should be emphasised

    • time and location, length of each session and number of sessions.

  • Commissioners, public health teams and providers should raise awareness of the programmes among health professionals who may refer children and young people. This includes GPs and staff involved in the National Child Measurement Programme and the Healthy Child Programme. For example, the programme could be publicised through health professional networks and by offering training sessions on the programmes and how to make referrals.

Recommendation 7 Raising awareness of lifestyle weight management programmes: health professionals, other professionals and voluntary organisations

Who should take action?

  • Health professionals, in particular, GPs, dietitians, health visitors, school nurses and those involved in delivering the National Child Measurement Programme and the Healthy Child Programme.

  • Schools, colleges, early years organisations, children's centres and looked-after children's teams and other professionals who work with children and young people. For example, youth workers, social workers, and pastoral care workers.

What action should they take?

  • Health professionals should tell the parents or carers of children and young people who have been identified as being overweight or obese about local lifestyle weight management programmes. They should explain what these involve and how they can take part (including whether or not they can self-refer).

  • Other professionals who work with children and young people should raise awareness of lifestyle weight management programmes for overweight and obese children and young people. They should also raise awareness of how to enrol on them.

Recommendation 8 Formal referrals to lifestyle weight management programmes

Who should take action?

  • Children's community nurses, dietetic teams, GPs, health visitors, primary care teams, obesity specialists, paediatricians, school nurses and school healthcare teams.

What action should they take?

  • Where there are concerns about a child or young person's weight, weigh them in light clothing on clinically approved, regularly calibrated scales. In children older than 2 years, measure their height using a stadiometer. (See the Standard evaluation framework for weight management interventions page 32, for practical advice on weighing and measuring children).

  • Use the UK growth charts for children aged 4 years and older to determine BMI centile for their age and gender. Use the UK-WHO 0–4 years growth chart to determine if children younger than 4 are a healthy weight. Record this in the child or young person's health record.

  • Take account of their BMI centile, any obesity-associated diseases or conditions (comorbidities) they may have, or family medical history, and any psychosocial considerations, to determine whether referral to a lifestyle weight management programme is clinically appropriate.

  • Use tact and diplomacy to find out if the family and the child or young person accepts that the child or young person is overweight or obese. If they do accept this and it is clinically appropriate to refer them to a lifestyle weight management programme, explain the potential benefits they will gain – and the risks of not addressing their child's weight. In addition:

    • identify and address any fears or concerns the child, young person or their family may have about attending (for example, fears of being the largest child on the programme, of having to do very strenuous activities, or being stigmatised for attending)

    • give the family information about the programme, or tell them where they can get this information

    • explain what can be realistically expected in terms of results over the duration of the programme itself (for example, explain that for growing children, maintaining their existing weight may be a realistic short-term aim)

    • explain that the more sessions of a programme they attend, the greater the likelihood of success.

  • Assess whether the child or young person and their family are ready and willing to be referred. If they are ready, refer them to an effective lifestyle weight management programme (see recommendation 3).

  • If the family is not ready to attend a programme:

  • If children or young people need specialist support to manage their weight, refer them to specialist obesity services (if available) or to paediatric services.

  • If there are concerns about the child or young person's mental wellbeing related to their weight, use the local pathway to refer them to CAMHS. Ensure their GP is informed.

Recommendation 9 Providing ongoing support: health professionals

Who should take action?

  • Children's community nurses, dietetic teams, GPs, health visitors, members of primary care teams, obesity specialists, paediatricians and school nurses and school healthcare teams.

What action should they take?

  • Health professionals should use feedback from the programmes to help regularly monitor progress and provide ongoing support. They should acknowledge that:

    • for children who are growing taller, avoiding further weight gain is a realistic short-term aim that can have a positive impact in the longer term

    • for young people who are no longer growing taller, ultimately they need to lose weight to improve their BMI, and they should also aim to acquire the knowledge and skills they need to make long-term behaviour changes

    • it is important to maintain changes in behaviour once the programme is completed

    • improvements in diet and physical activity can have positive health benefits, independent of any effect on weight or BMI

    • improvements in psychosocial outcomes (such as sense of wellbeing, self-efficacy, self-esteem and self–perception) are considered important health benefits for overweight and obese children and young people.

  • After the programme has been completed, health professionals should continue to monitor the child or young person's BMI centile when the opportunity arises and at 6 months and 1 year after they complete the programme.

  • If the child or young person's BMI centile begins to increase, or if they or their parents or carers express concerns about their weight (or sustaining changes in their behaviour), discuss the possible causes. If necessary, consider another referral to the same or an alternative lifestyle weight management programme that may better address the needs of the family. Or consider referral to specialist obesity services (if available), or to a paediatrician.

Recommendation 10 Providing ongoing support: lifestyle weight management programmes

What action should they take?

  • With the participants' consent, providers should send feedback to their referring GP or healthcare professional.

  • Offer all participants ongoing support when they have completed the programme. This support should be offered for at least the first year and longer, if possible, depending on the family's needs. Offer a range of options including follow-up sessions at different times and in easily accessible and acceptable venues.

  • Tell participants about local services and activities that may provide further support to help them manage their weight, for example, local leisure services and walking or cycling groups.

Recommendation 11 Lifestyle weight management programme staff: training

What action should they take?

  • Ensure staff are trained to deliver the weight management programme they will be working on. Ensure the training has been developed with the input of, and is regularly reviewed by, a multi-disciplinary team of professionals (see recommendation 2). Ensure staff training needs are regularly reviewed and addressed.

  • Ensure programme staff treat overweight and obese children, young people and their families with empathy, by making them aware of:

    • the reasons why some children and young people may have difficulty managing their weight

    • the experiences they may face in relation to their weight

    • the anxieties they and their families may have about attending the programme

    • the way in which obesity is perceived by different communities

    • the issues they may need to consider to ensure activities are culturally acceptable.

  • Train staff:

    • to accurately measure and record height and weight and to determine BMI centile using age- and gender-specific charts

    • to help parents and carers recognise that their child is overweight or obese and the benefits of addressing their weight

    • to use a locally approved comorbidities assessment tool, where available, to determine whether lifestyle weight management programmes are appropriate, or whether they should see their GP for a referral to a specialist obesity service or other specialist services (for example, paediatric services)

    • to identify any concerns about a child or young person's mental wellbeing and how to refer them to their GP for onward referral to CAMHS

    • in how to comply with statutory requirements and local policies relating to safeguarding and information governance.

Recommendation 12 Lifestyle weight management programme staff: knowledge and skills

What action should they take?

  • Ensure staff have the necessary knowledge and skills to deliver multi-component programmes to children, young people and their families. This includes knowledge and skills in relation to: childhood obesity management, diet and physical activity. It may also include training in behaviour-change techniques and psychological approaches (for example, motivational interviewing).

  • Ensure there are staff available who can provide parenting skills training. Also ensure there are staff trained in practical food preparation.

  • Ensure staff are able to empathise and communicate effectively with the family. They should be able to work collaboratively with them and tailor interventions for individual needs. They should also be able to lead group work and set an appropriate pace when delivering the programme. In addition, they should be able to judge when changes in behaviour have become embedded, before introducing further changes.

  • Ensure staff can review progress and provide constructive feedback. They should be able to help children, young people and their families to identify possible reasons for relapse and use problem-solving techniques to address these.

  • Identify any gaps in staff knowledge or skills (or a lack of confidence). Address any gaps through training.

Recommendation 13 Training in how to make referrals to a lifestyle weight management programme

Who should take action?

  • Employers.

  • Professional bodies responsible for setting competencies and designing continuous professional development programmes for health professionals.

What action should they take?

Ensure health professionals:

  • Understand why some children and young people may have difficulty managing their weight and the experiences that they may face in relation to their weight.

  • Are aware of how obesity is viewed in different cultures and the issues they may need to consider to ensure any recommended activities are culturally acceptable. See Promoting physical activity for children and young people (NICE public health guidance 17).

  • Can accurately measure and record height and weight and determine BMI centile, using age- and gender-specific charts.

  • Can raise the issue of weight management confidently and sensitively. They should be able to help parents and carers identify when their child is overweight or obese and understand the benefits of addressing their weight.

  • Are familiar with the local obesity care or weight management pathway and any locally approved comorbidities assessment tools.

  • Can assess whether referral to a lifestyle weight management service is appropriate, or whether they should be referred to specialist obesity services or other specialist services (for example, paediatric services).

  • Can identify suitable lifestyle weight management programmes for children, young people and their families and can provide them with information and ongoing support (see recommendations 9 and 10).

Recommendation 14 Supporting lifestyle weight management programme staff and those making programme referrals

Who should take action?

What action should they take?

  • If those involved in referring to, or delivering, lifestyle weight management programmes lack the confidence and skills to discuss weight management, offer them support and training.

  • If staff identify that the reason for their lack of confidence is a result of being overweight or obese themselves, offer them access to weight management programmes.

See also recommendation 9 in 'Obesity: working with local communities' (NICE public health guidance 42).

Recommendation 15 Monitoring and evaluating programmes

Who should take action?

What action should they take?

  • Ensure monitoring focuses on sustaining changes in the longer term. Include the following in the data reported:

    • numbers recruited, percentage completing the programme and percentage followed up at 6 months and at 1 year after completing the programme

    • for all those recruited, BMI and BMI z score a) at recruitment to the programme b) at completion of the programme c) 6 months after completing the programme and d) 1 year after completing the programme.

  • Ensure other measured outcomes reflect the aim of the programme and relate to factors that can support or contribute towards a reduction in BMI. These could include: improvements in diet and physical activity, a reduction in sedentary behaviour and improvements in self-esteem. (See Standard evaluation framework for weight management interventions for examples of other possible outcome measures.)

  • Ensure data collection tools are validated for the age range or population group the programme addresses and are feasible and affordable in practice settings. Do not rely on self-reported measures of height or weight, or interpretations of BMI based on them.

  • Monitor any variation in the numbers recruited, numbers completing and the proportion of people retained by the programme, according to population subgroup.

  • Collect data on:

    • Variations in outcomes, according to age, gender, ethnicity and socioeconomic status (for example, as indicated by the postcode of participants), so that the impact on health inequalities can be assessed.

    • The route through which participants were referred to programmes including any self-referrals. Use this information to identify areas where awareness of available programmes is low and where referral rates might be increased.

    • The views of participants: areas they found helpful and areas for improvement. Ensure the views of everyone who has participated are collected (including those who did not complete the programme).

    • The views of staff delivering the programme and of those referring participants to it. Use the information to identify any practical or process issues that may need addressing.

  • Commissioners should evaluate the service using data on outcomes and the cost of promotion and delivery.

  • Commissioners should regularly review monitoring and evaluation data and use it to amend and improve the service.

See also recommendation 10 in 'Obesity: working with local communities' (NICE public health guidance 42).



[1] Several classification systems are used in the UK to define 'obesity' and 'overweight' in children. In the analysis of population surveys such as the National Child Measurement Programme and the Health Survey for England (HSE), children over the 85th centile, and on or below the 95th centile, are classified as being 'overweight'. Children over the 95th centile are classified as being 'obese'. However, the NCMP uses the clinical cut-off points described above when providing feedback about the BMI of individual children to parents and carers.

  • National Institute for Health and Care Excellence (NICE)