Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.
com
Education & Practice Online First, published on November 7, 2016 as 10.1136/archdischild-2015-309729
1
Department of Endocrinology,
Birmingham Childrens Hospital
NHS Foundation Trust,
Birmingham, UK
2
Institutes of Metabolism and
Systems Research, University of
Birmingham, Birmingham, UK
3 children who are obese in their early
Centre for Endocrinology,
Diabetes and Metabolism,
Birmingham Health Partners,
Birmingham, UK
Correspondence to
Dr Renuka Dias, Department of
Paediatric Endocrinology and
Diabetes, Birmingham Childrens
Hospital NHS Foundation Trust,
Steelhouse Lane, Birmingham B4
6NH, UK;
r.dias.1@bham.ac.uk
Received 9 December 2015
Revised 25 September 2016
Accepted 27 September 2016
To cite: Kumaran A, Sakka S,
Dias RP. Arch Dis Child Educ
Pract Ed Published Online
First: [ please include Day
Month Year] doi:10.1136/
archdischild-2015-309729
Kumaran A, et al. Arch Dis Child Educ Pract Ed 2016;0:15. doi:10.1136/archdischild-2015-309729
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Obesity in children: recent NICE
guidance
Anitha Kumaran,1 Sophia Sakka,1 Renuka P Dias1,2,3
BACKGROUND
Despite a levelling off in obesity rates,
3 out of 10 children in England aged
215 years were either overweight or
obese in 2011.1 Seventy-nine per cent of
teens are likely to remain obese as adults.
Consequently, they will be at greater risk
of conditions such as type 2 diabetes,
non-alcoholic fatty liver disease, hyper-
tension and psychological morbidity
starting in adolescence,2 as well as coron-
ary heart disease and some cancers in
adulthood.35 This high proportion of
overweight or obese children poses finan-
cial challenges for the National Health
Service (NHS).3
The focus of this review is on aspects
pertaining to children from two recently
published guidelines from the National
Institute for Health and Care Excellence
(NICE) (box 1). NICE also has a suite of
previous guidelines for managing obesity
(box 1).
INFORMATION ABOUT THE CURRENT
GUIDELINES
In 2006, NICE produced guidance on
obesity prevention (clinical guideline
43).6 In November 2014, part of the
guidance was updated due to newly avail-
able evidence on diet, surgery and
follow-up for adults and published as
Identification, assessment and manage-
ment of overweight and obesity in chil-
dren, young people and adults. NICE
clinical guidance 189.7 Although the
updated evidence mostly pertains to
adults, the guideline and some amend-
ments for children and young persons
(aged 2 years and older) that are relevant
to all tiers of service (figure 1) are sum-
marised below.
In July 2015, NICE published a
population-level approach to prevent
overweight and obesity entitled
Prevention and lifestyle weight manage-
ment in children and young people.
GUIDELINE REVIEW
NICE quality standard 948 aimed at
local authorities, NHS organisations,
schools and providers of lifestyle weight
management programmes, which is also
summarised below.
UNDERLYING EVIDENCE BASE
The Guideline Development Groups and
the specialist committee consisted of pae-
diatricians, general practitioners (GPs),
paediatric and adult endocrinologists,
bariatric surgeons, dieticians, psycholo-
gists, nurses, consultants in public health
and patient representatives. A variety of
evidence was used in formulation of the
guidelines, ranging from randomised con-
trolled trials to expert narrative reviews
and expert consensus.
KEY RECOMMENDATIONS
NICE clinical guideline 189
Diagnosis and assessment of overweight/obesity in
children and young people
Age-specific and gender-specific body mass
index (BMI) centile charts must be the only
tool to identify overweight (>91st centile)
and obese children (>98th centile).
Where available, BMI z-scores or the
Royal College of Paediatrics and Child
Health UK WHO growth charts9 may
be used to calculate BMI in children
and young people and the childhood
and puberty close monitoring form
may be used for longitudinal BMI mon-
itoring in children over 4 years.
Waist circumference is not recommended
as a routine measure but can be used to
give additional information on the risk of
developing other long-term health
problems.
Explore presenting symptoms, current
eating and exercise patterns, views and
beliefs regarding this, previous attempts to
lose weight, and readiness and confidence
to make changes.
Assessment of comorbidities (such as
hypertension, hyperinsulinemia, dyslipi-
daemia, type 2 diabetes and obstructive
1
 Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.com

Guideline review

Box 1 Resources: National Institute for Health and Care Excellence (NICE) guidelines on obesity

Recent guidelines reviewed in this article

1. Identification, assessment and management of overweight and obesity in children, young people and adults. NICE clin-
ical guidance 189 (2014):
https://nice.org.uk/guidance/cg189 (link to full guidance)
https://www.nice.org.uk/guidance/cg189/resources (link to tools and resources)
https://www.nice.org.uk/guidance/cg189/ifp/chapter/about-this-information (link to information for the public)
2. Prevention and lifestyle weight management in children and young people NICE quality standard 94 (2015):
http://nice.org.uk/guidance/qs94
3. Public Health Englands healthier, more sustainable catering: provides information for those involved in purchasing food
and drink and provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving
size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives :http://www.
nhs.uk/change4life/Pages/change-for-life.aspx
Previous NICE guidance on obesity
CG43 Obesity prevention (December 2006, updated March 2015)
PH17 Promoting physical activity for children and young people (2009).
PH27 Weight management before, during and after pregnancy ( July 2010).
PH42 Obesity: working with local communities (November 2012).
PH46 Body mass index and waist circumference thresholds for intervening to prevent ill health among black, Asian and
other minority ethnic groups ( June 2013).
PH44 Physical activity: brief advice for adults in primary care (May 2013).
PH47 Managing overweight and obesity among children and young people: lifestyle weight management services (October
2013).
PH49 Behaviour change: individual approaches ( January 2014).
PH53 Managing overweight and obesity in adultslifestyle weight management services (May 2014)
NG7 Preventing excess weight gain (March 2015)
NICE has developed an obesity pathway ( part of CG189), which links all obesity-related guidance, as well as a related
pathway on physical activity:
https://pathways.nice.org.uk/pathways/obesity
https://pathways.nice.org.uk/pathways/physical-activity

sleep apnoea) should be considered if BMI at or above
98th centile. Assessment should include blood pressure,
fasting lipid profile, HbA1c, liver function tests, fasting
insulin, glucose and oral glucose tolerance test.
Referral and management
Clinical intervention, that is, lifestyle changes (table 1),
should be considered for children with BMI at or above
91st centile. For children who are growing taller, avoid-
ing further weight gain is a realistic short-term aim that
can have a positive impact in the longer term.
Make a formal referral to multicomponent lifestyle man-
agement programmes for children and young people
who can see benefits or losing weight. People not ready
for change must be given information on the benefits of
losing weight, healthy eating and increased physical
activity, and followed up in 36 months.
Any comorbidity should be managed when identified,
rather than waiting until weight loss occurs. This should
also include mental well-being, and onward referral
made to child and adolescent mental health services
(CAMHS) as appropriate.
Children with comorbidities and complex needs (such
as learning difficulties) may benefit from referral to
tier 3 services including evaluation of endocrine func-
tion for the assessment of underlying causes of obesity
(see figure 1).
Involve safeguarding if required (there is a general reluc-
tance to do this for overweight children compared with
underweight children).
When choosing treatments, the following factors should
be considered:
the persons individual preference and social circum-
stance, and the experience and outcome of previous
treatments (including whether there were any
barriers);
their level of risk, based on BMI and waist
circumference;
any comorbidity.
Tailor decisions and care to the needs and views of the
family and child, and in partnership with them. Where
appropriate, parents (of children aged <12 years) must
be encouraged to take responsibility for lifestyle
changes.

2 Kumaran A, et al. Arch Dis Child Educ Pract Ed 2016;0:15. doi:10.1136/archdischild-2015-309729

 Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.com

Guideline review

Figure 1 Tiers of management (see also National Health Service Englands report of the working group into: joined up clinical
pathways for obesity). Patients can self-refer into tier 2 services directly or be referred. Tier 3 and 4 services are referral-only and
engagement in tier 3 does not automatically lead to surgery. *Who has not responded to previous tier interventions; **Has to have
engaged in tier 3 services prior to entry. GP, general practitioner.

Table 1 Lifestyle changes

Lifestyle changes Interventions

Behaviour strategies Stimulus control

Self-monitoring
Goal setting
Rewards for reaching goals
Problem solving
Praise success and encourage parents to role model desired behaviours
Physical activity 60 min of daily moderate or greater intensity physical activity
Overweight children may need more than 60 min
Activity can be over one session or split over several sessions of 10 min duration
Discourage inactive behaviours (television, computer games)
Provide opportunities to increase daily exercise (walking, cycling, stairs)
Opportunity and support for regular and structured activity (football, swimming, dancing)
Diet Flexible and individual approach tailored to food preferences aiming at reducing energy intake
Avoid restrictive and nutritionally unbalanced diets as they are ineffective and can be harmful
Should be age appropriate in line with healthy eating advice
Energy intake should be below energy expenditure for the overweight and obese and changes must be sustainable

Pharmacological and surgical interventions in overweight
and obese children and young people
Pharmacological interventions
Are recommended only for children >12 years of age if
physical comorbidities (eg, orthopaedic, sleep apnoea)
and severe psychological comorbidities are present.
In children <12 years of age, the use of these unlicensed
drugs must be restricted to those with severe
comorbidities.
Orlistat should be prescribed and monitored by a special-
ist paediatric service. A 612-month trial is recom-
mended with regular review to assess effectiveness,
adverse effects and adherence.
Drug treatment may be continued in primary care with a
shared care protocol and may be used to maintain
weight. Supplements should be added to ensure adequate
micronutrient intake.
Arrangements must be made for appropriate healthcare
professionals to offer information, support and
counselling on additional diet, physical activity and
behavioural strategies when drug treatment is
prescribed.
Information on patient support programmes must also
be provided.
Bariatric surgery
Bariatric surgery may be considered only in exceptional
circumstances if physiological maturity has been achieved
in children with BMI >40 kg/m2 or 35 kg/m2 with
comorbidities.

Kumaran A, et al. Arch Dis Child Educ Pract Ed 2016;0:15. doi:10.1136/archdischild-2015-309729 3

 Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.com
Guideline review
Surgery should be undertaken only by a multidisciplin-
ary team that can provide paediatric expertise in
preoperative and postoperative assessment and have
access to suitable equipment and staff trained to use
them.
Comprehensive psychological, educational, family and
social assessment must be undertaken before bariatric
surgery.
Full medical evaluation, including genetic screening to
exclude rare, treatable causes of obesity, should be
assessed prior to surgery.
All surgeons must have specialist experience and training
in bariatric surgery and submit data to the national clin-
ical audit.
Following surgery, a follow-up care package must be pro-
vided for 2 years, and after discharge from bariatric
service annual follow-up to assess nutritional needs and
supplementation should take place.
NICE quality standard 94
Includes a set of specific measurable statements to
achieve quality improvements to prevent children
and young people from becoming overweight or
obese. The quality standards (box 2) are relevant
to local authorities, NHS organisations, schools
and providers of lifestyle weight management
programmes.
Box 2 List of quality standards for prevention and
lifestyle weight management in children and young
people (QS94)
Vending machines in local authority and National
Health Service (NHS) venues should offer healthy*
food and drink options.
Details of nutritional information on menus should
be visible at local authority and NHS venues.
Healthy food and drink choices should be displayed
prominently in local authority and NHS venues.
An up-to-date list of local lifestyle weight manage-
ment programmes should be publicly available and
accessible.
Overweight or obese children and young people, and
their carers should be given information about local
lifestyle weight management programme.
Family members/carers of children and young people
should be invited to attend lifestyle weight manage-
ment programmes, regardless of their weight.
Children and young people, and their parents or
carers, should be able to access data on attendance,
outcomes and the views of participants and staff
from lifestyle weight management programmes.
Sedentary behaviour should be reduced.
*Food and drink that helps people to meet the eat well
plate guidance recommendations, and which does not
contain high levels of salt, fat, saturated fat or sugar.
4 Kumaran A, et al. Arch Dis Child Educ Pract Ed 2016;0:15. doi:10.1136/archdischild-2015-309729
What should I start doing?
Only use BMI centiles and z-scores on the Royal College
of Paediatrics and Child Health growth charts to assess if
overweight or obese.
Involve CAMHS and raise safeguarding concerns as
appropriate.
Proactively identify and treat comorbidities at diagnosis.
If conventional treatment is not successful, refer for pos-
sible consideration of drug treatment or surgery.
What can I continue to do as before?
Raise the issue of weight management confidently and
sensitively with children and their parents/carers, and
help them to understand the benefits of addressing their
weight.
Encouraging healthy eating and increased physical
activity.
What should I stop doing?
Do not use bioimpedance as a substitute for BMI as a
measure of general adiposity.
Do not use unduly restrictive and nutritionally unba-
lanced diets because they are ineffective in the long term
and can be harmful.
Do not give orlistat to children for obesity unless pre-
scribed by a multidisciplinary team with expertise in
drug monitoring; psychological support; behavioural
interventions; interventions to increase physical activity
and interventions to improve diet.
The co-prescribing of orlistat with other drugs aimed at
weight reduction is not recommended.
CRITICAL APPRAISAL BOX
The updated guidance recognises the need to consider
lifestyle changes tailored to the child and familys needs,
involve safeguarding if required, identify comorbidities,
including mental health and psychological issues (box 3).
However, there are a number of other considerations
that the guideline does not expand upon:
1. At present, the national child measurement programme
data are only collected at reception and year 6. There
are no GP, public health quality and outcomes frame-
work to detect childhood obesity so there is a risk of
missing children with an obesity problem. While
emphasis has been placed on management by trained
professionals, there is no clarification regarding require-
ments of training, and currently there are no formal
training programmes geared to help healthcare personnel
deliver the objectives of the guidelines.
2. Rarely some children have a pathological cause for their
obesity (eg, hypothalamic tumours, endocrine dysfunc-
tion, single gene disorders and syndromes such as
Prader-Willi). Paediatricians must be aware of this diag-
nostic pitfall and investigate further those children with
obesity and short stature, poor growth velocity, dys-
morphic features, intellectual impairment and congenital
abnormalities suggestive of a syndrome.
3. Assessment of comorbidities has been emphasised, but at
present there are no validated tools to do so.
 Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.com
Box 3 Clinical bottom line
Body mass index centiles from Royal College of
Paediatrics and Child Health growth charts must be
used to assess whether a child or young person is
overweight or obese.
Guidance, tools and resources are provided for a
structured approach to prevent, identify, assess and
manage obesity at the level of primary and secondary
care.
While the role, responsibility for different tiers of
service remain unclear, this guidance can enable
commissioners and providers to set standards of care.
Ideally care should be delivered by multidisciplinary
teams with specific training, competence and
expertise.
Children with complex needs and comorbidities must
be managed by specialist obesity services.
Drugs and bariatric surgery can be considered in
exceptional circumstances.
4. There is a general lack of commissioning and hence lack
of services above tier 2,10 which makes the advice almost
impossible to follow in certain areas in the country.
5. There is also little standardisation nationally of weight
management programmes in children and families, and
hence the ability for research in these areas will vary
depending on the service available to them.
UNRESOLVED CONTROVERSIES AND FUTURE
RESEARCH
There is a lack of data on effective lifestyle weight
management programmes for children and young
people with disabilities, learning difficulties or other
special needs, and for children younger than 6 years.
Research is also required to identify barriers and facili-
tators for the uptake and completion of a lifestyle
weight management programme (such as the impact
of socioeconomic group, ethnicity, gender and age).
Standardised reporting for the behavioural therapy
and cognitive behavioural therapy components used
by programme developers are lacking. In addition,
there is no evidence on the lifetime effects of weight
management programmes. Safety and outcome data
following drug treatment and bariatric surgery in
young people are also required.
There is a great need for dedicated tier 3 and 4 ser-
vices in the UK to monitor comorbidities and lead
research, specifically highlighted in the guidelines as
follows:
Kumaran A, et al. Arch Dis Child Educ Pract Ed 2016;0:15. doi:10.1136/archdischild-2015-309729
Guideline review
Do postoperative lifestyle intervention programmes
(exercise, behavioural or dietary) improve weight loss
and weight loss maintenance following bariatric surgery?
What is the long-term effect of bariatric surgery on
diabetes-related complications and quality of life in
people with type 2 diabetes compared with optimal
medical treatment?
What are the indications for bariatric surgery in pre-
pubertal children with significant obesity and comorbid-
ities, what type of surgery must be considered and what
are the long-term outcomes of bariatric surgery in chil-
dren and young people with obesity?
What is the best way to deliver obesity management
interventions to people with particular conditions asso-
ciated with increased risk of obesity (such as people with
a physical disability that limits mobility, a learning dis-
ability or enduring mental health difficulties)?
Contributors RPD: conception and design; RPD, AK and SS:
manuscript draft; RPD: manuscript revision and final approval.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer
reviewed.
REFERENCES
1 Health and Social Care Information Centre. Health survey for
england, trend tables. Health and Social Care Information
Centre, 2012.
2 Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of
type 2 diabetes mellitus in children and adolescents. Lancet
2007;369:182331.
3 Government Office for Science. Foresight: Tackling obesities:
future choices. Project report. 2nd edn. Government Office for
Science, 2007.
4 National Obesity Observatory. Obesity and mental health.
National Obesity Observatory, 2011.
5 Department of Health. Healthy lives, healthy people: a call
to action on obesity in England. Department of Health,
2011.
6 National Institute for Health and Care Excellence. Obesity: the
prevention, identification, assessment and management of
overweight and obesity in adults and children. NICE, 2006.
(NICE Clinical Guideline 43).
7 National Institute for Health and Care Excellence.
Identification, assessment and management of overweight and
obesity in children, young people and adults. NICE, 2014
(NICE Clinical Guideline 189).
8 National Institute for Health and Care Excellence. Prevention
and lifestyle weight management in children and young people.
NICE, 2015 (NICE quality standard 94).
9 Royal College of Paediatrics and Child Health. UK-WHO
growth charts.
10 Report of the working group into: Joined up clinical pathways
for obesity. NHS England Publications, 2014.
5
 Downloaded from http://ep.bmj.com/ on March 20, 2017 - Published by group.bmj.com

Obesity in children: recent NICE guidance

Anitha Kumaran, Sophia Sakka and Renuka P Dias

Arch Dis Child Educ Pract Ed published online November 7, 2016

Updated information and services can be found at:

http://ep.bmj.com/content/early/2016/11/07/archdischild-2015-309729

These include:

References This article cites 1 articles, 0 of which you can access for free at:
http://ep.bmj.com/content/early/2016/11/07/archdischild-2015-309729
#BIBL
Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections Child health (356)
Guideline review (29)
Health education (36)
Health promotion (42)
Obesity (nutrition) (22)
Obesity (public health) (22)
Childhood nutrition (56)
Childhood nutrition (paediatrics) (32)
Liver disease (14)
Diabetes (24)
Diet (32)
Drugs: cardiovascular system (46)
Epidemiologic studies (96)
Metabolic disorders (70)
Pregnancy (54)
Reproductive medicine (97)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/