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. Dedicated resources should be allocated for action.

Local authorities and partners

• Local authorities should work with local partners, such as industry and voluntary organisations, to create and manage more safe spaces for incidental and planned physical activity, addressing as a priority any concerns about safety, crime and inclusion, by

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

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

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  ensuring buildings and spaces are designed to encourage people to be more physically active (for example, through positioning and signing of stairs, entrances and walkways)

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  considering in particular people who require tailored information and support, especially inactive, vulnerable groups.

Early years settings

• Nurseries and other childcare facilities should:

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  minimise sedentary activities during play time, and provide regular opportunities for enjoyable active play and structured physical activity sessions

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  implement Department for Education and Skills, Food Standards Agency and Caroline Walker Trust^[1] guidance on food procurement and healthy catering.

Workplaces

• Workplaces should provide opportunities for staff to eat a healthy diet and be physically active, through

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  active and continuous promotion of healthy choices in restaurants, hospitality, vending machines and shops for staff and clients, in line with existing Food Standards Agency guidance

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  working practices and policies, such as active travel policies for staff and visitors

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  a supportive physical environment, such as improvements to stairwells and providing showers and secure cycle parking

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  recreational opportunities, such as supporting out-of-hours social activities, lunchtime walks and use of local leisure facilities.

Self-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 (see recommendation 1.1.7.1 for details of best practice standards).

1.1.1. Recommendations for the public

This section has been replaced by Maintaining a healthy weight and preventing excess weight gain among adults and children (2015) NICE guideline NG7.

1.1.2. The NHS

The following recommendations are made specifically for health professionals and managers in the NHS, but may also be relevant to health professionals in other organisations. Recommendations in other sections may also be relevant for NHS health professionals working with local authorities and other organisations.

These recommendations are for:

• senior managers, GPs, commissioners of care and directors of public health
• staff in primary and secondary care, particularly those providing interventions, including public health practitioners, nurses, behavioural psychologists, physiotherapists, GPs, pharmacists, trained counsellors, registered dietitians, public health nutritionists and specifically trained exercise specialists.

With specific training, staff such as pharmacy assistants or support staff in general practices may also be able to give advice and support.

Implementing these recommendations will contribute to the English target to halt the annual obesity in children younger than 11 years by 2010, and similar initiatives in Wales. Recommendations can be delivered through local strategic partnerships and other local agreements and partnerships.

Section 3 has links to tools to help with implementing the recommendations and meeting training needs. In many cases, implementation will involve organisations working together in partnership.

Primary care staff should engage with target communities, consult on how and where to deliver interventions and form key partnerships and ensure that interventions are person centred.

Tailoring advice to address potential barriers (such as cost, personal tastes, availability, time, views of family and community members) is particularly important for people from black and minority ethnic groups, people in vulnerable groups (such as those on low incomes) and people at life stages with increased risk for weight gain (such as during and after pregnancy, menopause or smoking cessation). Many of the recommendations below also highlight the need to provide ongoing support - this can be in person, or by phone, mail or internet as appropriate.

1.1.3. Local authorities and partners in the community

The environment in which people live may influence their ability to maintain a healthy weight - this includes access to safe spaces to be active and to an affordable, healthy diet. Planning decisions may therefore have an impact on the health of the local population. Fundamental concerns about safety, transport links and services need to be addressed. Effective interventions often require multidisciplinary teams and the support of a broad range of organisations.

These recommendations apply to:

• senior managers and budget holders in local authorities and community partnerships, who manage, plan and commission services such as transport, sports and leisure and open spaces (not just those with an explicit public health role)
• staff providing specific community-based interventions.

Implementation of these recommendations is likely to contribute to local area agreements and other local agreements and targets. The need to work in partnership should be reflected in the integrated regional strategies and reviewed regularly.

Recommendations that refer to the planning of buildings, and stair use in particular, should be implemented in the context of existing building regulations and policies, particularly in relation to access for disabled people.

Section 3 has links to tools to help with implementing the recommendations, meeting training needs, evaluating the impact of action and working in partnership with other organisations.

1.1.4. Early years settings

The preschool years (ages 2–5) are a key time for shaping lifelong attitudes and behaviours, and childcare providers can create opportunities for children to be active and develop healthy eating habits, and can act as positive role models.

These recommendations apply to:

• directors of children’s services
• children and young people’s strategic partnerships
• staff, including senior management, in childcare and other early years settings
• children’s trusts, children’s centres, Healthy Start and Sure Start teams
• trainers working with childcare staff, including home-based childminders and nannies.

Implementing these recommendations will contribute to meeting the target to halt the annual rise in obesity in children younger than 11 years by 2010 and to implementing the England and Wales National Service Frameworks for children, young people and maternity services (the Children’s NSFs for England and Wales), and ‘Every child matters’ and similar initiatives in Wales.

Section 3 has links to tools to help with implementing the recommendations and meeting training needs.

1.1.5. Schools

During their school years, people often develop life-long patterns of behaviour that affect their ability to keep a healthy weight. Schools play an important role in this by providing opportunities for children to be active and develop healthy eating habits, and by providing role models. Improving children’s diet and activity levels may also have wider benefits: regular physical activity is associated with higher academic achievement, better health in childhood and later life, higher motivation at school and reduced anxiety and depression.

There is no evidence that school-based interventions to prevent obesity, improve diet and increase activity levels foster eating disorders or extreme dieting or exercise behaviour.

These recommendations apply to:

• directors of children’s services
• staff, including senior management, in schools
• school governors
• health professionals working in or with schools
• children and young people’s strategic partnerships
• children’s trusts.

Implementing these recommendations will contribute to meeting the target to halt the annual rise in obesity in children younger than 11 years by 2010 and implementing the Children’s NSFs for England and Wales, the National Healthy Schools Programme (and the Welsh Network of Healthy Schools Schemes), and ‘Every child matters’ and similar initiatives in Wales.

Section 3 has links to tools to help with implementing the recommendations and meeting training needs.

Recommendations that refer to the planning of buildings, and stair use in particular, should be implemented in the context of existing building regulations and policies, particularly in relation to access for disabled people.

1.1.6. Workplaces

The workplace may have an impact on a person’s ability to maintain a healthy weight both directly, by providing healthy eating choices and opportunities for physical activity (such as the option to use stairs instead of lifts, staff gym, cycle parking and changing and shower facilities), and indirectly, through the overall culture of the organisation (for example, through policies and incentive schemes). Taking action may result in significant benefit for employers as well as employees.

These recommendations apply to:

• senior managers
• health and safety managers
• occupational health staff
• unions and staff representatives
• employers’ organisations and chambers of commerce
• health professionals working with businesses.

The recommendations are divided into:

• those that all organisations may be able to achieve, with sufficient input and support from a range of staff, including senior management
• those that are resource intensive and may only be fully achieved by large organisations with on-site occupational health staff, such as the NHS, public bodies and larger private organisations.

The recommendations are likely to build on existing initiatives - such as catering awards, Investors in People and Investors in Health, and the Corporate Health Standard in Wales.

Section 3 has links to tools to help with implementing the recommendations and meeting training needs.

Recommendations that refer to the planning of buildings, and stair use in particular, should be implemented in the context of existing building regulations and policies, particularly in relation to access for disabled people.

1.1.7. Self-help, commercial and community programmes

This section has been replaced by Managing overweight and obesity in adults - lifestyle weight management services (2014) NICE guideline PH53.

Why this is important

Many studies of interventions to prevent and manage obesity were of short duration, with little or no follow-up, were conducted outside the UK and were poorly reported. There is an urgent need for randomised controlled trials (or other appropriately designed studies, in line, for example, with the ‘TREND statement’^[4]), with at least 12 months’ postintervention follow-up.

Studies should use validated methods to estimate body fatness (BMI), dietary intake and physical activity, and should assess the benefits of measures additional to BMI (such as waist circumference in children). Details of the intervention, provider, setting and follow-up times should be reported. The development of a ‘CONSORT’-type^[4] statement for public health research is strongly recommended. In research on managing obesity in clinical settings, the effects of different levels of intensity of non-pharmacological interventions and follow-up should be assessed. Further research is also needed on the effectiveness of pharmacological and surgical interventions in people with comorbidities such as type 2 diabetes or cardiovascular disease.

Why this is important

There is little UK-based evidence on the effectiveness of multicomponent interventions among key at-risk groups (for example, young children and families and black and minority ethnic groups), vulnerable groups (for example, looked-after children and young people, lower-income groups and people with disabilities) and people at vulnerable life stages (for example, women during and after pregnancy and people stopping smoking).

Interventions should be undertaken in ‘real world’ everyday clinical and non-clinical settings and should investigate how the setting, mode and source of delivery influence effectiveness. There is a need for research evaluating multicomponent interventions to manage obesity in primary care, because factors such as the types of participant, the training of staff and the availability of resources may affect the results. Future research should:

• assess the feasibility of using in the UK interventions shown to be effective in other developed countries
• collect sufficient data to assess how the effectiveness of the intervention varies by age, gender, ethnic, religious and/or social group
• consider the value of corroborative evidence, such as associated qualitative studies on acceptability to participants
• consider the potential negative effects of an intervention as well as the intended positive effects (particularly for studies of children and young people).

Why this is important

There is little evidence on the cost effectiveness of interventions, partly because of a lack of outcome measures that are amenable to health economic evaluations. Much of the evidence on the effectiveness of prevention strategies concerns crude measures such as average weight loss rather than response rates. Follow-up is usually short. In clinical research, more information from quality-of-life questionnaires throughout the intervention and follow-up period would help assess how valuable any clinical improvement is to the individual. This would allow greater comparison between types of intervention and improve assumptions made in cost-effectiveness analyses. It would be valuable to run cost-effectiveness studies in parallel with clinical trials, so that patient-level data can be collected.

Why this is important

There are considerable barriers to the implementation of interventions, including organisational structures and personal views of both health professionals and patients. The enthusiasm and motivational skills of the health professional providing support and advice are likely to be key, and interventions may be more effective when tailored to the individual’s needs.Further research is required to identify:

• what elements make an intervention effective and sustainable
• what staff training is needed.

4.5.1. Population trends in overweight and obesity

Data on the prevalence of overweight and obesity at national and regional levels (with subgroup analysis by age, gender and social status) are published annually by the ‘Health survey for England’ (HSE) and the ‘Welsh health survey’. The continued collection of such data at national and regional levels is strongly recommended. The ‘Health survey for England’ also provides detailed data on children and on black and minority ethnic groups about every 5 years. To allow full analysis of trends, more frequent collection of data among these and other vulnerable groups at national and local levels is encouraged.

4.5.2. Local and national action

Although considerable action is being undertaken at a local level that could directly or indirectly have an impact on the prevention or management of obesity, little evaluation is being undertaken. This observation is reflected in the 2005 Dr Foster survey^[5] of obesity services, which found that only 15% of primary care organisations monitored interventions such as physical activity programmes and exercise on prescription. Many potentially important broader community policies are also not evaluated in terms of their health impact - examples include congestion charging, which is implemented to address traffic rather than health issues, and safer routes to schools.

It is therefore recommended that all local action - including action in childcare settings, schools and workplaces - be monitored and evaluated with the potential impact on health in mind. An audit of health impact should also be undertaken after each change has taken place. The need to evaluate projects should be taken into account when planning funding for those projects. It is recommended that the evaluation of local initiatives is carried out in partnership with local centres that have expertise in evaluation methods, such as health authorities, public health observatories and universities.

There is also limited high quality long-term evaluation of national schemes that are implemented locally and may have an impact on weight, diet or physical activity (such as interventions promoting a ‘whole-school approach’ to health, Sure Start initiatives and exercise referral schemes for children). It is therefore recommended that all current and future actions be rigorously monitored and evaluated with their potential health impact in mind. Evaluation of campaigns (including social marketing campaigns) should go beyond the ‘reach’ of the campaigns and more fully explore their effectiveness in changing behaviour.

4.5.3. Clinical practice

In clinical practice there is a need to set up a registry on the use of orlistat in young people. There is also a need to undertake arrangements for prospective audits of bariatric surgery, so that the outcomes and complications of different procedures, their impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.

Public health

• Professor Gerard Hasting
  Director, Institute for Social Marketing and Centre for Tobacco Control Research, University of Stirling and the Open University
• Dr Gill Hawksworth
  Community Pharmacist and Lecturer/Practitioner, University of Bradford
• Ms Wendy Hicks
  Specialist Nurse, Weight Management Service, Newcastle Primary Care Trust
• Mrs Anne Hollis
  Clinical Manager for School Nursing, Fareham and Gosport Primary Care Trust
• Dr Ira Madan, nominated by the Faculty of Occupational Medicine
  Consultant Occupational Physician, Guy’s and St Thomas’ NHS Trust
• Mr Lindley Owen
  Manager, Sustrans Cornwall
• Dr David Wilson
  Senior Lecturer in Paediatric Gastroenterology and Nutrition, Child Life and Health, University of Edinburgh

Clinical management

• Dr John Buckley
  Exercise Physiologist, Keele University
• Laurel Edmunds
  Research Psychologist and Independent Consultant, Bristol Royal Children’s Hospital
• Dr Nicholas Finer
  Senior Research Associate, University of Cambridge, and Honorary
  Consultant in Obesity Medicine, University of Cambridge Hospitals Trust
• Mr Tam Fry
  Honorary Chair, Child Growth Foundation
• Professor Philip James
  Chairman of the International Obesity Taskforce and Senior Vice President of the International Association for the Study of Obesity
• Mr David Kerrigan
  Consultant Surgeon, University Hospital Aintree
• Dr Krystyn Matyka
  Senior Lecturer in Paediatrics, University of Warwick
• Professor Mary Rudolf
  Consultant Paediatrician and Professor of Child Health, Leeds Primary Care Trust and the University of Leeds
• Russell Viner
  Consultant/Honorary Senior Lecturer in Adolescent Medicine and Endocrinology, University College London Hospitals and Great Ormond St Hospital
• Professor Jane Wardle
  Professor of Clinical Psychology, University College London

Project Team, Centre for Public Health Excellence

• Dr Hugo Crombie
  Analyst
• Dr Adrienne Cullum
  Analyst (Technical Lead)
• Mr Simon Ellis
  Associate Director (Methodology)
• Professor Mike Kelly
  Director
• Dr Caroline Mulvihill
  Analyst
• Ms Susan Murray
  Analyst
• Dr Bhash Naidoo
  Analyst
• Ms Karen Peploe
  Analyst
• Dr Nichole Taske
  Analyst