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Education & Practice Online First, published on November 7, 2016 as 10.1136/archdischild-2015-309729
GUIDELINE REVIEW
Guideline review
Box 1 Resources: National Institute for Health and Care Excellence (NICE) guidelines on obesity
sleep apnoea) should be considered if BMI at or above Children with comorbidities and complex needs (such
98th centile. Assessment should include blood pressure, as learning difficulties) may benefit from referral to
fasting lipid profile, HbA1c, liver function tests, fasting tier 3 services including evaluation of endocrine func-
insulin, glucose and oral glucose tolerance test. tion for the assessment of underlying causes of obesity
(see figure 1).
Referral and management Involve safeguarding if required (there is a general reluc-
Clinical intervention, that is, lifestyle changes (table 1), tance to do this for overweight children compared with
should be considered for children with BMI at or above underweight children).
91st centile. For children who are growing taller, avoid- When choosing treatments, the following factors should
ing further weight gain is a realistic short-term aim that be considered:
can have a positive impact in the longer term. the persons individual preference and social circum-
Make a formal referral to multicomponent lifestyle man- stance, and the experience and outcome of previous
agement programmes for children and young people treatments (including whether there were any
who can see benefits or losing weight. People not ready barriers);
for change must be given information on the benefits of their level of risk, based on BMI and waist
losing weight, healthy eating and increased physical circumference;
activity, and followed up in 36 months. any comorbidity.
Any comorbidity should be managed when identified, Tailor decisions and care to the needs and views of the
rather than waiting until weight loss occurs. This should family and child, and in partnership with them. Where
also include mental well-being, and onward referral appropriate, parents (of children aged <12 years) must
made to child and adolescent mental health services be encouraged to take responsibility for lifestyle
(CAMHS) as appropriate. changes.
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.
Pharmacological and surgical interventions in overweight weight. Supplements should be added to ensure adequate
and obese children and young people micronutrient intake.
Pharmacological interventions Arrangements must be made for appropriate healthcare
Are recommended only for children >12 years of age if professionals to offer information, support and
physical comorbidities (eg, orthopaedic, sleep apnoea) counselling on additional diet, physical activity and
and severe psychological comorbidities are present. behavioural strategies when drug treatment is
In children <12 years of age, the use of these unlicensed prescribed.
drugs must be restricted to those with severe Information on patient support programmes must also
comorbidities. be provided.
Orlistat should be prescribed and monitored by a special-
ist paediatric service. A 612-month trial is recom- Bariatric surgery
mended with regular review to assess effectiveness, Bariatric surgery may be considered only in exceptional
adverse effects and adherence. circumstances if physiological maturity has been achieved
Drug treatment may be continued in primary care with a in children with BMI >40 kg/m2 or 35 kg/m2 with
shared care protocol and may be used to maintain comorbidities.
Guideline review
Surgery should be undertaken only by a multidisciplin- What should I start doing?
ary team that can provide paediatric expertise in Only use BMI centiles and z-scores on the Royal College
preoperative and postoperative assessment and have of Paediatrics and Child Health growth charts to assess if
access to suitable equipment and staff trained to use overweight or obese.
them. Involve CAMHS and raise safeguarding concerns as
Comprehensive psychological, educational, family and appropriate.
social assessment must be undertaken before bariatric Proactively identify and treat comorbidities at diagnosis.
surgery. If conventional treatment is not successful, refer for pos-
Full medical evaluation, including genetic screening to sible consideration of drug treatment or surgery.
exclude rare, treatable causes of obesity, should be
What can I continue to do as before?
assessed prior to surgery.
Raise the issue of weight management confidently and
All surgeons must have specialist experience and training
sensitively with children and their parents/carers, and
in bariatric surgery and submit data to the national clin-
help them to understand the benefits of addressing their
ical audit.
weight.
Following surgery, a follow-up care package must be pro-
Encouraging healthy eating and increased physical
vided for 2 years, and after discharge from bariatric
activity.
service annual follow-up to assess nutritional needs and
supplementation should take place. What should I stop doing?
Do not use bioimpedance as a substitute for BMI as a
NICE quality standard 94
measure of general adiposity.
Includes a set of specific measurable statements to
Do not use unduly restrictive and nutritionally unba-
achieve quality improvements to prevent children
lanced diets because they are ineffective in the long term
and young people from becoming overweight or
and can be harmful.
obese. The quality standards (box 2) are relevant
Do not give orlistat to children for obesity unless pre-
to local authorities, NHS organisations, schools
scribed by a multidisciplinary team with expertise in
and providers of lifestyle weight management
drug monitoring; psychological support; behavioural
programmes.
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.
Box 2 List of quality standards for prevention and
lifestyle weight management in children and young
people (QS94) CRITICAL APPRAISAL BOX
The updated guidance recognises the need to consider
lifestyle changes tailored to the child and familys needs,
Vending machines in local authority and National involve safeguarding if required, identify comorbidities,
Health Service (NHS) venues should offer healthy* including mental health and psychological issues (box 3).
food and drink options. However, there are a number of other considerations
Details of nutritional information on menus should that the guideline does not expand upon:
be visible at local authority and NHS venues. 1. At present, the national child measurement programme
Healthy food and drink choices should be displayed data are only collected at reception and year 6. There
prominently in local authority and NHS venues. are no GP, public health quality and outcomes frame-
An up-to-date list of local lifestyle weight manage- work to detect childhood obesity so there is a risk of
ment programmes should be publicly available and missing children with an obesity problem. While
accessible. emphasis has been placed on management by trained
Overweight or obese children and young people, and professionals, there is no clarification regarding require-
their carers should be given information about local ments of training, and currently there are no formal
lifestyle weight management programme. training programmes geared to help healthcare personnel
Family members/carers of children and young people deliver the objectives of the guidelines.
should be invited to attend lifestyle weight manage- 2. Rarely some children have a pathological cause for their
ment programmes, regardless of their weight. obesity (eg, hypothalamic tumours, endocrine dysfunc-
Children and young people, and their parents or tion, single gene disorders and syndromes such as
carers, should be able to access data on attendance, Prader-Willi). Paediatricians must be aware of this diag-
outcomes and the views of participants and staff nostic pitfall and investigate further those children with
from lifestyle weight management programmes. obesity and short stature, poor growth velocity, dys-
Sedentary behaviour should be reduced. morphic features, intellectual impairment and congenital
*Food and drink that helps people to meet the eat well abnormalities suggestive of a syndrome.
plate guidance recommendations, and which does not 3. Assessment of comorbidities has been emphasised, but at
contain high levels of salt, fat, saturated fat or sugar. present there are no validated tools to do so.
Guideline review
Do postoperative lifestyle intervention programmes
Box 3 Clinical bottom line (exercise, behavioural or dietary) improve weight loss
and weight loss maintenance following bariatric surgery?
Body mass index centiles from Royal College of What is the long-term effect of bariatric surgery on
Paediatrics and Child Health growth charts must be diabetes-related complications and quality of life in
used to assess whether a child or young person is people with type 2 diabetes compared with optimal
overweight or obese. medical treatment?
Guidance, tools and resources are provided for a What are the indications for bariatric surgery in pre-
structured approach to prevent, identify, assess and pubertal children with significant obesity and comorbid-
manage obesity at the level of primary and secondary ities, what type of surgery must be considered and what
care. are the long-term outcomes of bariatric surgery in chil-
While the role, responsibility for different tiers of dren and young people with obesity?
service remain unclear, this guidance can enable What is the best way to deliver obesity management
commissioners and providers to set standards of care. interventions to people with particular conditions asso-
Ideally care should be delivered by multidisciplinary ciated with increased risk of obesity (such as people with
teams with specific training, competence and a physical disability that limits mobility, a learning dis-
expertise. ability or enduring mental health difficulties)?
Children with complex needs and comorbidities must
be managed by specialist obesity services. Contributors RPD: conception and design; RPD, AK and SS:
Drugs and bariatric surgery can be considered in manuscript draft; RPD: manuscript revision and final approval.
exceptional circumstances. Competing interests None declared.
Provenance and peer review Commissioned; externally peer
reviewed.
4. There is a general lack of commissioning and hence lack
of services above tier 2,10 which makes the advice almost
REFERENCES
impossible to follow in certain areas in the country. 1 Health and Social Care Information Centre. Health survey for
5. There is also little standardisation nationally of weight england, trend tables. Health and Social Care Information
management programmes in children and families, and Centre, 2012.
hence the ability for research in these areas will vary 2 Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of
depending on the service available to them. type 2 diabetes mellitus in children and adolescents. Lancet
2007;369:182331.
UNRESOLVED CONTROVERSIES AND FUTURE 3 Government Office for Science. Foresight: Tackling obesities:
RESEARCH future choices. Project report. 2nd edn. Government Office for
Science, 2007.
There is a lack of data on effective lifestyle weight
4 National Obesity Observatory. Obesity and mental health.
management programmes for children and young
National Obesity Observatory, 2011.
people with disabilities, learning difficulties or other 5 Department of Health. Healthy lives, healthy people: a call
special needs, and for children younger than 6 years. to action on obesity in England. Department of Health,
Research is also required to identify barriers and facili- 2011.
tators for the uptake and completion of a lifestyle 6 National Institute for Health and Care Excellence. Obesity: the
weight management programme (such as the impact prevention, identification, assessment and management of
of socioeconomic group, ethnicity, gender and age). overweight and obesity in adults and children. NICE, 2006.
Standardised reporting for the behavioural therapy (NICE Clinical Guideline 43).
and cognitive behavioural therapy components used 7 National Institute for Health and Care Excellence.
by programme developers are lacking. In addition, Identification, assessment and management of overweight and
there is no evidence on the lifetime effects of weight obesity in children, young people and adults. NICE, 2014
(NICE Clinical Guideline 189).
management programmes. Safety and outcome data
8 National Institute for Health and Care Excellence. Prevention
following drug treatment and bariatric surgery in
and lifestyle weight management in children and young people.
young people are also required. NICE, 2015 (NICE quality standard 94).
There is a great need for dedicated tier 3 and 4 ser- 9 Royal College of Paediatrics and Child Health. UK-WHO
vices in the UK to monitor comorbidities and lead growth charts.
research, specifically highlighted in the guidelines as 10 Report of the working group into: Joined up clinical pathways
follows: for obesity. NHS England Publications, 2014.
These include:
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Notes