More than a quarter of adults are now classified as obese and a further 42% of men and a third of women are overweight^[1]. It is an immense problem for society – with huge personal health cost to individuals and an enormous financial cost to the NHS.

NICE has updated 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. The guideline also considers more information on the effectiveness and safety of very-low-calorie diets in helping people lose weight.

Commenting on the newly updated guideline, Professor Mark Baker, Centre for Clinical Practice director, said: “As a nation we are getting heavier. The number of people classified as obese has nearly doubled over the last 20 years and continues to rise. Obesity is directly linked to type 2 diabetes, fatty liver disease, cancer, high blood pressure, heart disease, stroke, arthritis and it affects people’s mental health. The financial implications of obesity are huge – 10% of the NHS budget is used to treat diabetes and its complications alone. It is a major issue, if not the major issue, for the health service in the coming years.

“NICE has published a range of guidelines to help prevent obesity and to help people lose weight. This guideline focuses on the clinical aspects – what a doctor should do to help an obese or overweight person. It sets out clearly what help and treatments should be offered and in what order.”

This newly updated NICE guideline says that very-low-calorie diets should only be used in certain circumstances; it includes new recommendations on weight loss surgery for people with type 2 diabetes and on follow up after surgery.

Professor John Wilding, Professor of Medicine and Honorary Consultant Physician in Diabetes, Endocrinology and General Medicine, University of Liverpool and Aintree University Hospitals NHS Foundation Trust, said: “Obesity has different causes – for some people it is down to lifestyle, for others it is genetics, but for most it is somewhere in between. But, whatever the reason, everyone who has a weight problem should be focusing on making changes to their diet and lifestyle. Weight loss surgery is not a quick fix or easy option, and although effective, it isn’t the answer for everyone. At the moment only 1% of people eligible for surgery actually have it; most people should try diet and exercise first. However, if someone is obese and they are diagnosed with type 2 diabetes it is really important that their doctor talks to them about the benefits undergoing surgery could provide for them.

“The new guideline also looked at very-low-calorie diets – after considering how well they work and if the weight loss can be sustained, we have recommended that they should not be used routinely for people who are obese. But we are not ruling them out entirely, they may be considered for people who have a clinical need to lose weight quickly, such as before joint replacement surgery.”

Dr Rachel Batterham, Head of Obesity and Bariatric services at University College London Hospital NHS Trust; and Head of the Centre for Obesity Research, UCL (University College London), said: “NICE already recommends that weight loss surgery should be available as an option for people with a BMI over 35, who have failed to lose weight through medical weight loss programmes and if they have another medical condition that could be improved if they lost weight. However, we now know that surgery can make a real difference for people with recently diagnosed type 2 diabetes, so the new guideline now recommends that if someone is diagnosed with type 2 diabetes and their BMI is 35 or over then they should be offered an early, rapid assessment for weight loss surgery.

“Type 2 diabetes is a chronic, disabling condition; it can lead to kidney disease, amputations and blindness. At the moment 1 in 6 NHS beds is taken up by people with diabetes and its complications. Bariatric surgery can help because it changes the way the body deals with sugar. Around 60% of people who undergo surgery will have more control over their diabetes immediately and they are less likely to have diabetes related illness.

“Bariatric surgery is not an easy option. It cannot be used alone. It must be accompanied with changes to diet, activity levels and lifestyle. There is an initial cost of around £6,000 in the short term, but preventing the long-term complications of diabetes is great for the individual and will save the NHS money.”

Professor Alex Blakemore, representing patients and carers on the group that developed the guideline, has had the surgery: “Surgery isn’t a magic spell or an easy option, it helps you lose weight, but it doesn’t happen overnight and there is still a lot of work to do, it requires changing your lifestyle.

“One of the most surprising effects for me was the rapid effect it has on diabetes, some of which happens immediately, before weight loss. On the day that I had my own surgery, another woman had her operation too. She had diabetes and was on insulin and already had severe complications including constant pain from nerve damage. Four days later she went home without her insulin and within six weeks she was off her other medication too. That all happened before weight loss. Sadly, although her diabetes went into remission the complications remained, if she had had surgery earlier, this could have been prevented.

“The updated guideline puts a lot of emphasis on follow up after surgery, ensuring that people have support to help improve their diets, be more active and make lifestyle changes to ensure they lose the weight and keep it off.”

The updated guideline will be available on the NICE website from Thursday 27 November 2014. Recommendations include:

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, as part of a multicomponent weight management strategy, for people who are obese and who have a clinically-assessed need to rapidly lose weight (for example, people who need joint replacement surgery or who are seeking fertility services). Ensure that: the diet is nutritionally complete; the diet is followed for a maximum of 12 weeks (continuously or intermittently); the person following the diet is given ongoing clinical support.

Bariatric surgery for people with recent-onset type 2 diabetes

• Offer an expedited assessment for bariatric surgery to people with a BMI of 35 or over who have recent-onset type 2 diabetes^[2]  as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent)
• Consider an assessment for bariatric surgery for people with a BMI of 30–34.9 who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent)
• Consider an assessment for bariatric surgery for people of Asian family origin who have recent-onset type 2 diabetes  at a lower BMI than other populations (see recommendation 1.2.8) as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).

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:

• monitoring nutritional intake (including protein and vitamins) and mineral deficiencies
• monitoring for comorbidities
• medication review
• dietary and nutritional assessment, advice and support
• physical activity advice and support
• psychological support tailored to the individual
• information about professionally-led or peer-support groups.

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

For more information call the NICE press office on 0845 003 7782 or out of hours on 07775 583 813.

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 most commonly used method in the UK is a gastric bypass.

About the guidance

2. The guidance on the identification, assessment and management of overweight and obesity in children, young people and adults will be available at /guidance.nice.org.uk/CG189 from Thursday 27 November 2014. 
3. In ‘Bariatric surgery for obesity’ the former National Obesity Observatory, now Public Health England’s obesity knowledge and intelligence team, reports a rise in bariatric surgery from around 470 in 2003/04 to over 6500 in 2009/10. The First Annual Report (March 2010) of the National Bariatric Surgery Register reported that more than 7000 of these operations were carried out between April 2008 and March 2010.
4. Classification of obesity:

5. 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.