Obesity
Obesity - Summary
The terms 'overweight' and 'obesity' are used to describe excess body fat.
Obesity results from an imbalance between energy intake and energy expenditure. Many factors can influence this, including lifestyle, genetics, medical conditions, and medication.
Degrees of overweight and obesity are classified according to body mass index (BMI), calculated by dividing a person's weight in kilograms by the square of their height in metres:
Overweight — BMI of 25–29.9 kg/m2
Obesity l — BMI of 30–34.9 kg/m2
Obesity ll — BMI of 35–39.9 kg/m2
Obesity lll — BMI of greater than or equal to 40 kg/m2
The prevalence of obesity is increasing; in the UK 26% of all men and women are obese (BMI 30 kg/m2 or more) and 68% of men and 58% of women are overweight or obese (BMI 25 kg/m2 or more).
Obesity is associated with an increased risk of developing a number of chronic diseases and conditions including: type 2 diabetes, coronary heart disease, hypertension and stroke, asthma, depression, metabolic syndrome, dyslipidaemia, certain cancers, gastro-oesophageal reflux disease, gallbladder disease, reproductive problems, osteoarthritis and back pain, obstructive sleep apnoea, breathlessness, and psychological distress. Most of the complications of obesity can be reduced by weight loss.
The cornerstones of obesity management in adults are dietary change and increased physical activity, supported by behavioural interventions.
Drug treatment with orlistat should be considered as an adjunct to lifestyle interventions for people with BMI 30 kg/m2 or greater, or BMI 28 kg/m2 or greater and associated risk factors (such as type 2 diabetes, hypertension, or dyslipidaemia).
Weight-loss surgery may be an option if non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months for people with BMI 40 kg/m2 or greater, or BMI 35 kg/m2 or greater and other significant disease (for example type 2 diabetes, hypertension, severe mobility problems) that could be improved if they lost weight.
Surgery is a first-line option in adults with a BMI greater than 50 kg/m2.
Have I got the right topic?
This CKS topic covers the management of overweight and obese adults and the use of drugs for weight loss.
This CKS topic incorporates recommendations from the National Institute for Health and Clinical Excellence (NICE) guideline Obesity: guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the Scottish Intercollegiate Guideline Network (SIGN) guideline Management of Obesity [SIGN, 2010].
This CKS topic does not cover the management of overweight and obese children, or weight management in pregnancy and eating disorders, or the primary prevention of obesity. It does not provide healthcare professionals with detailed, multidisciplinary solutions to obesity, or in-depth information about behavioural interventions. It also does not cover in detail how to maintain weight loss or how dietary recommendations might be tailored for people with conditions such as diabetes or hyperlipidaemia.
There are separate CKS topics on a number of conditions for which obesity is a risk factor: Angina, CVD risk assessment and management, Depression, Hypertension - not diabetic, Lipid modification - CVD prevention, and Osteoarthritis. The CKS topic on Smoking cessation deals with issues relating to weight gain in people who quit smoking.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September to October 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made; recommendations for starting drug treatment have been amended in line with the product license for orlistat (Xenical®).
Previous changes
March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.
February 2010 — minor update. Advice on interactions between orlistat and levothyroxine and antiepileptic drugs has been added to the Prescribing information section. Issued in February 2010.
January 2010 — updated. On 21 January 2010 the European Medicines Agency's (EMEA) Committee for Medicinal Products for Human Use (CHMP) recommended the suspension of the Marketing Authorisation for sibutramine (Reductil®) because the benefits no longer outweigh the risks [EMEA, 2010]. This CKS topic has been updated to reflect the EMEA's decision. Recommendations regarding when to consider prescribing sibutramine, as well as prescribing information and prescriptions have been removed. Issued in January 2010.
October 2008 — updated. On 23 October 2008 EMEA CMHP recommended the suspension of the Marketing Authorisation for rimonabant (Acomplia®) because the benefits no longer outweigh the risks [EMEA, 2008]. This CKS topic has been updated to reflect the EMEA's decision. Recommendations regarding when to consider prescribing rimonabant, as well as prescribing information and prescriptions have been removed. Issued in November 2008.
July 2008 — minor update to incorporate the recommendation from NICE that rimonabant may now be prescribed as an alternative to orlistat or sibutramine. Prescribing rimonabant scenario added.
May 2008 — minor update to text to reflect updated advice from the MHRA regarding rimonabant. Issued June 2008.
June to September 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
There have been no major changes to the recommendations. This update incorporates recommendations from the National Institute for Health and Clinical Excellence guideline Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.
July 2006 — minor update. Information regarding orlistat and reduced efficacy of oral contraceptives has been included.
July–September 2005 — reviewed. Validated in December 2005 and issued in February 2006.
March 2002 — reviewed. Validated in June 2002 and issued in July 2002.
June 2001 — updated to incorporate Guidance on the use of orlistat for the treatment of obesity in adults, technology appraisal number 22, issued by the National Institute for Health and Clinical Excellence, and statistics on obesity published by the National Audit Office. Validated in July 2001 and issued in October 2001.
Update
New evidence
Evidence-based guidelines
No new guidelines since 1 August 2012.
HTAs (Health Technology Assessments)
No new HTA's since 1 August 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 August 2012.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Chan, E.W., He, Y., Chui, C.S., et al. (2013) Efficacy and safety of lorcaserin in obese adults: a meta-analysis of 1-year randomized controlled trials (RCTs) and narrative review on short-term RCTs. Obesity Reviews epub ahead of print. [Abstract]
Flegal, K.M., Kit, B.K., Orpana, H., and Graubard, B.I. (2013) Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 309(1), 71-82. [Abstract] [Free Full-text]
Jurgens, T.M., Wheland, A.M., Killian, L., et al. (2012) Green tea for weight loss and weight maintenance in overweight or obese adults (Cochrane Review). The Cochrane Library. Issue 12. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Lim, S.S., Norman, R.J., Davies, M.J., and Moran, L.J. (2013) The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obesity Reviews 14(2), 95-109. [Abstract]
Ma, Y., Yang, Y., Wang, F., et al. (2013) Obesity and risk of colorectal cancer: a systematic review of prospective studies. PLoS One 8(1), e53916. [Abstract] [Free Full-text]
Sergentanis, T.N., Antoniadis, A.G., Gogas, H.J., et al. (2012) Obesity and risk of malignant melanoma: a meta-analysis of cohort and case-control studies. European Journal of Cancer 49(3), 642-657. [Abstract]
Primary evidence
No new randomized controlled trials published in the major journals since 1 August 2012.
New policies
No new policies since 1 August 2012.
New safety alerts
No new safety alerts since 1 August 2012.
Changes in product availability
No changes in product availability since 1 August 2012.
Goals and outcome measures
Goals
Weight management with risk-factor reduction (i.e. reduction of the risks that obesity carries for conditions such as cardiovascular disease, type 2 diabetes, and cancer), rather than major weight loss
Modest, sustainable weight loss
Ideally, the eventual body mass index (BMI) should be less than 25 kg/m2, but this should not be set as a goal unless it is thought to be realistically achievable
Audit criteria
Percentage of identified adult patients with a BMI > 30 who have a documented multi-component weight management plan setting out strategies for addressing changes in diet and activity levels, developed with the relevant health care professional.
Percentage of adult patients prescribed pharmacological treatment for obesity for whom it is clear that:
The potential benefits and limitations of the drug treatment were discussed prior to prescription, and,
Arrangements have been made for appropriate healthcare professionals to offer specific information, support and counselling on diet, physical activity and behavioural strategies.
QOF indicators
| Indicator | Points | Payment stages |
|---|---|---|
| OB 1The practice can produce a register of patients aged 16 years and over with a BMI greater than or equal to 30 in the preceding 15 months | 8 | — |
| DM 2The percentage of patients with diabetes whose notes record BMI in the preceding 15 months | 1 | 50–90% |
| MH 12The precentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months. | 4 | 50–90% |
Background information
Definition
What is it?
The terms 'overweight' and 'obesity' are used to describe excess body fatness which can affect a person's health and well being [National Heart Forum, 2007].
The National Institute for Health and Clinical Excellence classify degrees of overweight and obesity according to a person's body mass index (BMI) [NICE, 2006b]:
Overweight — BMI of 25–29.9 kg/m2.
Obesity l — BMI of 30–34.9 kg/m2.
Obesity ll — BMI of 35–39.9 kg/m2.
Obesity lll — BMI of greater than or equal to 40 kg/m2.
BMI should be interpreted with caution as it is not a direct measure of adiposity (for example in adults who are very muscular, or in those with muscle weakness or atrophy it is a less accurate measure of adiposity) [NICE, 2006b; SIGN, 2010].
A person's BMI is calculated by dividing their weight in kilograms by the square of their height in metres [SIGN, 2010]. An online calculator is available at www.nhs.uk.
Prevalence
How common is it?
In 2010 in the general population in England, 26% of men and 26% of women were obese (body mass index [BMI] of 30 kg/m2 or more).
In 2010 in the general population in England, 68% of men and 58% of women were overweight or obese (BMI of 25 kg/m2 or more).
Cause
What causes it?
Obesity results from an imbalance between energy intake and energy expenditure [Farooqi, 2010].
Many factors can influence this, including lifestyle, genetics, medical conditions, and medication.
Lifestyle factors
Food intake — household energy intake has declined since 1970, but this does not take into account the increased popularity of eating out (where food is likely to be higher in fat and sugar than that eaten at home). There is also a trend towards larger portions of many food items.
Physical inactivity — in 2008, the recommended target of 30 minutes of moderate intensity physical activity at least five times a week was only met by 39% of men and 24% of women.
Social and psychological factors — the habits and customs of a person's social network can affect their diet. Some people with low self-esteem or depression may over-consume foods high in fat, sugar, and calories ('comfort foods').
Economic changes — the more income a country has, the more people rely on labour-saving devices, which cause a decrease in physical activity and an increase in the amount of processed food consumed, as well as more meals eaten outside the home.
Genetics
Inherited factors contribute to differences in fat mass [Farooqi, 2010].
Genes are thought to contribute 25-40% to the variation in adiposity between different people [Maffeis, 2000].
The 'ob' (for 'obesity') gene controls the production of leptin in fat cells. 'Leptin' is derived from the Greek word leptos meaning thin. Genetic causes of obesity may include insensitivity of the hypothalamus to leptin, and functionally defective leptin [Hamilton et al, 1995; Saladin et al, 1995; Considine et al, 1996].
Medical conditions
Medical conditions that can cause or contribute to obesity include:
Hypothyroidism.
Cushing's syndrome.
Growth hormone deficiency.
Polycystic ovary syndrome.
Hypothalamic damage (e.g. tumour, trauma, surgery).
Genetic syndromes associated with hypogonadism (e.g. Prader-Willi syndrome, Laurence-Moon-Biedl syndrome).
Medication
Commonly used drugs that can lead to weight gain include [Malone, 2005; SIGN, 2010; BNF 64, 2012]:
Oral hypoglycaemic drugs — sulphonylureas, thiazolidinediones ('glitazones')
Insulin — when used in the treatment of type 2 diabetes
Antidepressants — tricyclics, mirtazapine, monoamine oxidase inhibitors (MAOIs)
Anticonvulsants — sodium valproate, gabapentin, vigabatrin
Antipsychotics — especially the atypical antipsychotics
Lithium
Corticosteroids
Beta-blockers
Pizotifen
Complications
What are the complications?
Obesity is an important health problem as it can contribute to the development or exacerbation of many different disorders, which have significant effects on demands on the health service and effects on the economy (for example from time off work) [House of Commons Health Committee, 2004; National Heart Forum, 2007].
Overweight and obesity are associated with an increased risk of developing a number of chronic diseases and conditions including:
Type 2 diabetes
Coronary heart disease
Hypertension and stroke
Asthma
Depression
Metabolic syndrome
Dyslipidaemia
Cancer
Gastro-oesophageal reflux disease (GORD)
Gallbladder disease
Reproductive problems
Osteoarthritis and back pain
Obstructive sleep apnoea
Breathlessness
Psychological distress
[National Heart Forum, 2007; SIGN, 2010]
Table 1 outlines the relative risk of someone who is obese developing certain health problems.
Table 1. Health problems associated with obesity in adults.| Relative risk* | Complications |
|---|---|
| > 3 | Type 2 diabetes |
| Gall bladder disease | |
| Hypertension | |
| Dyslipidaemia | |
| Insulin resistance | |
| Non-alcoholic fatty liver | |
| Sleep apnoea | |
| Breathlessness | |
| Asthma | |
| Social isolation and depression | |
| Daytime sleepiness and fatigue | |
| 2-3 | Coronary heart disease |
| Stroke | |
| Gout/hyperuricaemia | |
| Osteoarthritis | |
| Respiratory disease | |
| Hernia | |
| Psychological problems | |
| 1-2 | Cancer (e.g. breast, colon, endometrium) |
| Reproductive abnormalities/impaired fertility | |
| Polycystic ovaries | |
| Skin complications | |
| Cataract | |
| Varicose veins | |
| Musculoskeletal problems | |
| Back problems | |
| Stress incontinence | |
| Oedema/cellulitis | |
Prognosis
What is the prognosis?
Most of the complications of obesity can be reduced by weight loss [Farooqi, 2010].
In a prospective cohort study of 3457 people participating in the Framingham Heart Study, overweight and obesity were associated with decreased life expectancy [Peeters et al, 2003]:
In the overweight group (body mass index [BMI] 25–29.9 kg/m2):
Female non-smokers aged 40 years lost 3.3 years of life expectancy.
Male non-smokers aged 40 years lost 3.1 years of life expectancy.
In the obese group (BMI >= 30 kg/m2):
Female non-smokers aged 40 years lost 7.1 years of life expectancy.
Male non-smokers aged 40 years lost 5.8 years of life expectancy.
Excess mortality is greater with more severe obesity, and with earlier onset of obesity [National Heart Forum, 2007].
Diagnosis
Diagnosis of obesity
Confirming if a person is overweight or obese
How should I confirm if a person is overweight ot obese?
Calculate the person's body mass index (BMI) by dividing their weight in kilograms by the square of their height in metres. An online calculator is available at www.nhs.uk.
The National Institute for Health and Clinical Excellence classifies adults as overweight or obese using their BMI:
Overweight — BMI of 25–29.9 kg/m2.
Obesity l — BMI of 30–34.9 kg/m2.
Obesity ll — BMI of 35–39.9 kg/m2.
Obesity lll — BMI of greater than or equal to 40 kg/m2.
Interpret BMI with caution in very muscular adults, or in people with atrophy as it is a less accurate measure of adiposity in these groups.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [NICE, 2006b].
Management
Management
Scenario: Obesity - assessment/referral: covers the assessment of, and when to refer, someone who is overweight or obese.
Scenario : BMI 25-29.9 (overweight): covers the management of a person with a body mass index (BMI) of 25–29.9 kg/m2.
Scenario : BMI 30-34.9 (obesity I): covers the management of a person with a body mass index (BMI) of 30–34.9 kg/m2.
Scenario : BMI 35-39.9 (obesity II): covers the management of a person with a body mass index (BMI) of 35–39.9 kg/m2.
Scenario : BMI >= 40 (obesity III): covers the management of a person with a body mass index (BMI) 40 kg/m2 or more.
Scenario: Obesity - assessment/referral
Scenario: Assessment and referral of overweight or obese people
Assessing overweight or obese
How should I assess a person who is overweight or obese?
Assess:
Underlying causes and comorbidities (for example medical problems, medication, psychological and social factors).
Risk of developing complications of obesity (for example medical or psychological).
Lifestyle in terms of diet and exercise.
The potential health benefits of weight loss to the person.
The person's feelings about being overweight (for example beliefs, previous attempts to lose weight, and what was learnt).
The person's willingness and motivation to try to lose weight.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [NICE, 2006b] and the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006].
Introducing the issue of weight with someone
How should I first broach the issue of weight with someone?
Healthcare professionals should use clinical judgement when deciding whether to measure a person's height and weight. Opportunities include when a person registers at the practice and at consultations for conditions related to obesity (for example type 2 diabetes and cardiovascular disease).
Approach the subject of weight carefully because people who are overweight or obese may be sensitive about discussing it, or feel that their presenting problem is being overlooked.
Initiate a conversation about the person's weight if they appear to be overweight or obese and there are no reasons why this should not be discussed.
For example, offer to discuss their height and weight measurements, and if their body mass index is in the overweight or obese category, discuss the possible health implications of this.
Explain why excess weight can be problematic in terms of comorbidities and the chance of developing complications.
Discuss why gaining more weight may increase risks to health.
Make the person aware of the benefits of modest weight loss with regard to comorbidities and disease risk, particularly if they are obese (see Table 1).
Table 1. The benefits of a 10 kg weight loss in a person with obesity.| Aspect | Benefit |
|---|---|
| Mortality | 20–25% reduction in total mortality30–40% reduction in deaths related to diabetes40–50% reduction in obesity-related cancer deaths |
| Blood pressure(in people who are hypertensive) | 10 mmHg reduction in both systolic and diastolic values |
| Diabetes(in people who are newly diagnosed) | 30–50% reduction in fasting glucose15% reduction in HbA1c |
| Lipids | 10% reduction in total cholesterol15% reduction of low density lipoprotein cholesterol (LDL-C)30% reduction in triglycerides8% increase in high density lipoprotein cholesterol (HDL-C) |
| Other benefits | Improved lung function, insulin sensitivity, and ovarian functionReduced back pain, joint pain, breathlessness, and sleep apnoea |
Basis for recommendation
Basis for recommendation
This recommendation is based on the Department of Health Care Pathway for the management of overweight and obesity [DH, 2006].
Contributing factors and comorbidities
How should I assess for contributing factors and existing comorbidities?
Comorbidities should be managed at the time they are identified; treatment should not be delayed until the person has lost weight.
History:
Medical history:
Enquire into medical conditions that can contribute to overweight and obesity, or complications that may arise as a result of excess weight.
Pay particular attention to symptoms of comorbidities that might not be recognized (for example sleep apnoea).
Family history (for example family history of overweight and obesity, and comorbidities).
Drug history — identify medication that might cause weight gain.
Social history (for example lifestyle, diet, exercise, alcohol and smoking, work and leisure activities).
Examination:
Check blood pressure using a large arm cuff.
Investigations:
Check blood glucose and lipid profile, preferably on a fasting sample.
Consider other tests if appropriate on the basis of assessment findings (for example liver function tests, thyroid function tests).
Investigations can be useful in that they act as a baseline for future measurements.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b], the Department of Health care pathway for the management of overweight and obesity [DH, 2006], and guidelines from the National Obesity Forum [NOF, 2010] and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2010].
Risk of future obesity-related problems
How should I assess someone's risk of obesity-related health problems in the future?
Calculate the person's body mass index (BMI) if this has not already been done.
Measure waist circumference in people with a BMI less than 35 kg/m2.
Waist circumference is used to assess the amount of abdominal fat a person has, otherwise known as 'central' fat distribution.
This should be measured around the midpoint between the lowest rib and the top of the right iliac crest.
Using this information and Table 1, assess whether the person is at increased risk of cardiovascular and metabolic complications.
Asian people may be at higher risk, and older people at lower risk, for a certain BMI compared with the general population.
People with BMI 35kg/m2 or greater are at very high risk, regardless of waist circumference.
Ask about family history of diabetes (including gestational diabetes) and coronary heart disease.
Table 1. Classification of cardiovascular and metabolic disease risk by waist circumference in people who are overweight or in obesity class I.| BMI | Low§ | High§ | Very high§ |
| Overweight (BMI 25–29.9) | No increased risk | Increased risk | High risk |
| Obesity I (BMI 30–34.9) | Increased risk | High risk | Very high risk |
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b], the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006], and the Scottish Intercollegiate Guidelines Network (SIGN) guideline, Management of Obesity [SIGN, 2010].
Life-threatening problems are more likely to occur as body fatness increases, therefore identifying at what body mass index (BMI) the health risks to a person increase is important [National Heart Forum, 2007].
Central obesity (assessed by waist circumference) is linked to higher risks of type 2 diabetes and coronary heart disease [National Heart Forum, 2007].
People who are overweight (BMI 25–29.9 kg/m2) with a waist circumference of more than 94 cm in men and more than 80 cm in women, or people classed as obesity I (BMI 30–34.9 kg/m2) have an increased risk of developing long-term health problems. This risk increases proportionally to the person's waist circumference [NICE, 2006b].
If a person's BMI is equal to or greater than 35 kg/m2, waist circumference does not add a great deal to the measure of risk provided by the person's BMI [National Collaborating Centre for Primary Care, 2006].
The BMI of a person who is elderly has a lower correlation with their percentage body fat than in a young person, and is less strongly associated with cardiovascular morbidity. However, a reasonable correlation still persists [National Collaborating Centre for Primary Care, 2006].
Some ethnic groups (for example Asian people) have increased cardiovascular and metabolic risks at lower BMIs. There is no universal agreement whether the BMI classification should be adapted for this group [National Heart Forum, 2007]. However, NICE recommend that health professionals need to use clinical judgement when assessing risk factors in these groups of people [NICE, 2006b]. The World Health Organization (WHO) have proposed BMI cut-offs for Asian adults of 18.5–22.9 kg/m2 for a healthy weight, and 23 kg/m2 or more for overweight: 23–24.9 kg/m2 (at risk), 25–29.9 kg/m2 (obesity I), and 30 kg/m2 or more (obesity II) [WHO International Association for the Study of Obesity and International Obesity Task force, 2000].
There is also no globally applicable grading system of waist circumference for ethnic populations, but the International Diabetes Federation (IDF) and the WHO have suggested waist circumference thresholds for Asian adults of 90 cm (35 inches) or more for men, and 80 cm (31 inches) or more for women (the IDF definition includes South Asian and Chinese populations only) [WHO International Association for the Study of Obesity and International Obesity Task force, 2000; International Diabetes Federation, 2005; National Heart Forum, 2007].
Assessing readiness to lose weight
How should I assess a person's readiness to lose weight?
Determine if the person wants to lose weight at the present time.
Questions which may help to clarify a person's readiness to lose weight include:
Are you concerned about your weight?
How important is it for you to lose weight at the moment?
Do you believe that you could lose weight?
What would have to change in your life for you to be able to tackle your weight?
Is your weight affecting your life in any way at the moment?
Explore barriers to lifestyle change, for example:
Lack of knowledge about food, and how diet and exercise affect health.
Cost and availability of healthy foods and opportunity for exercise.
Safety concerns.
Lack of time.
Personal tastes.
Views of family and community members.
Low levels of fitness, or disability.
Low self-esteem and lack of assertiveness.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline Obesity: Guidance on the prevention, identification, and management of overweight and obesity in adults and children [NICE, 2006b], the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006], and a published literature review [Haslam and James, 2005]:
Motivation depends on the person accepting that obesity is a medical disorder.
It is estimated that less than one in five people are motivated to accept treatment to lose weight.
Encourage motivation by offering support, encouragement, and follow up from a weight management team.
Managing a person not ready to change their weight
What should I do if the person is not ready to change their weight?
Explore why the person does not feel ready to lose weight.
Offer the person the opportunity to return for further consultations when they are ready to discuss their weight again and are willing or able to make lifestyle changes.
Give information on the benefits of losing weight, healthy eating, and increased physical activity (for example a 'Why weight matters' card — for more information see the Department of Health website www.dh.gov.uk).
Stress that obesity has specific health implications and is not just a case of how a person looks.
Basis for recommendation
Basis for recommendation
This recommendation is based the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the care pathway for the management of overweight and obesity from the Department of Health [DH, 2006].
Referral
When should I refer a person who is overweight or obese?
Consider referral to a specialist obesity service if:
The underlying causes of overweight and obesity need to be assessed.
The person has complex disease states or needs that cannot be managed adequately in either primary or secondary care.
Conventional treatment has failed in primary or secondary care.
Specialist interventions (for example very low calorie diet for extended periods or surgery) may be needed.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
Scenario : BMI 25-29.9 (overweight)
Scenario : BMI 25-29.9 kg/m2 (overweight)
Approach to managing weight
How should I approach managing a person's weight?
Aim to help the person increase their physical activity levels and improve their diet and eating behaviour.
Consider the use of behavioural interventions to achieve this aim.
When deciding on treatment type, consider the person's:
Preferences.
Degree of overweight or obesity.
Level of risk (using body mass index and waist circumference, if appropriate).
Comorbidities.
Social circumstances.
Previous treatments.
The person's level of risk and their potential for health benefits from weight loss should be considered when deciding on the intensity of intervention.
Base weight loss targets on the person's co-morbidities and risks, rather than weight alone.
Aim for an overall 5–10% reduction in body weight (higher in people with BMI greater than 35 kg/m2).
Weekly weight loss should be no more than 1 kg.
The person should be given a copy of their main goals, according to their needs.
Offer a level of support appropriate to the person's needs.
Offer encouragement and praise for successes, however small.
Discuss the importance of developing skills for maintaining weight loss.
If a person declines intervention, offer them the opportunity to make contact in the future for support and advice if they change their mind.
Behavioural interventions
Behavioural interventions
Any behavioural intervention should be delivered with the support of an appropriately trained professional.
Behavioural interventions for adults should include the following strategies, as appropriate for the person:
Self monitoring of behaviour and progress
Stimulus control
Goal setting
Slowing rate of eating
Ensuring social support
Problem solving
Assertiveness
Cognitive restructuring (modifying thoughts)
Reinforcement of changes
Relapse prevention
Strategies for dealing with weight regain
The level of behavioural intervention will depend on the availability of local resources.
Basis for recommendation
Basis for recommendation
This recommendation is based the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the Scottish Intercollegiate Guidelines Network (SIGN) guideline, Management of Obesity [SIGN, 2010].
Targets for weight loss
In people with BMI 25–35 kg/m2, a 5-10% weight loss (approximately 5–10 kg) is required to produce a clinically significant reduction in cardiovascular disease and metabolic risk.
In those with a BMI greater than 35 kg/m2, obesity-related co-morbidities are already likely to exist, and a greater weight reduction may be required (15–20%) to obtain a sustained improvement in comorbidity.
Managing when BMI 25-29.9 (overweight)
How should I manage someone with a BMI 25-29.9 (overweight)?
Waist circumference low (< 80 cm for women or < 94 cm for men): offer general advice on healthy weight and lifestyle.
Waist circumference high (>= 80 cm for women or >= 94 cm for men): offer structured advice regarding diet and physical activity.
Consider starting drug treatment with orlistat in overweight people with body mass index (BMI) 28 kg/m2 and associated risk factors (such as type 2 diabetes, hypertension, or dyslipidaemia).
Drug treatment should only be considered once dietary and physical activity interventions have been evaluated.
Drug treatment should form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.
Basis for recommendation
Basis for recommendation
Recommendations for the level of intervention in someone who is overweight are from the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the manufacturer's Summary of Product Characteristics for Xenical® [ABPI Medicines Compendium, 2012].
There is good evidence that orlistat is effective in improving weight loss compared with placebo. After 12 months the median weight loss with orlistat (in combination with a weight-reducing diet) was 5.4 kg (range 3.3 to 7.6 kg).
Dietary advice
What advice should I give about diet?
Advice on dietary changes should take into account the person's food preferences and allow for flexible approaches to reducing calorie intake. The 'Your Weight, Your Health' booklet available from the Department of Health website, www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses diet as part of a healthy life.
Promote a diet which is in line with healthy eating recommendations, is acceptable to the person, and is sustainable in the long term.
Ensure that the person is aware of the changes they will need to make to their usual eating habits.
All healthy people over 5 years old should eat a balanced diet rich in fruit, vegetables, and starchy foods including:
Five portions of a variety of types of fruit and vegetables each day.
Meals based on starchy foods (for example bread, pasta, rice, and potatoes) — include high fibre varieties if possible.
Moderate amounts of milk and dairy products — should be low fat if possible.
Moderate amounts of protein-rich foods (for example meat, fish, eggs, beans, and lentils).
A reduction in the amounts of foods high in fat (especially saturated fat), sugar, and salt.
A reduction in alcohol intake (alcohol is high in calories).
Cooking using methods which reduce fat (for example grilling, steaming).
People should be encouraged to improve their diet even if they do not lose weight.
Diets that are recommended for sustainable weight loss are:
Those with a 600 kcal/day deficit (i.e. they contain 600 kcal less than the person needs to stay the same weight), or
Those which reduce calories by lowering the fat content (low-fat diets).
Low-calorie diets (1000–1600 kcal/day) are less likely to be nutritionally complete, but can be considered in combination with expert support and intensive follow up.
Very-low-calorie diets (less than 1000 kcal/day) may be used, under specialist clinical supervision, for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), if a person is obese and has reached a plateau in weight loss.
Any diet of less than 600 kcal/day should be used only under specialist clinical supervision.
Do not use unduly restrictive and nutritionally unbalanced diets.
In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the associated NICE quick reference guide [NICE, 2006c]. Recommendations for healthy eating are based on the Balance of Good Health from the Food Standards Agency [DH, 2006; National Heart Forum, 2007].
There is evidence to suggest that dietary interventions in people with overweight or obesity are effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful [NICE, 2006b].
People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits [NICE, 2006b].
Advice about physical activity
What advice should I give about physical activity?
Any advice given about exercise activities and duration should consider the person's current physical fitness and ability.
If appropriate, encourage the person to:
Reduce the amount of time they spend being inactive (for example watching television or using a computer).
Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (this can be in one session, or split into a number of sessions each lasting at least 10 minutes).
Build up to these recommended levels, encouraging the person to set realistic goals, and to adjust these as their physical fitness improves.
Recommended types of physical activity include:
Activities that can be incorporated into everyday life, such as brisk walking, gardening, or cycling.
Supervised exercise programmes.
Other activities (for example swimming, aiming to walk a certain number of steps each day, or stair climbing).
A pedometer may be useful for motivation and to help a person monitor their activity levels. If appropriate, adults can gradually work towards a goal of 10,000 steps a day.
The 'Your Weight, Your Health' booklet available from the Department of Health website www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses incorporating exercise into a healthy life.
Encourage the person to take more exercise even if it does not lead to weight loss because it has other health benefits, such as reducing the risk of type 2 diabetes and cardiovascular disease.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
There is evidence to suggest that physical activity in people with overweight or obesity is effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Adults should be encouraged to increase their physical activity even if it does not result in weight loss, because of the other health benefits physical activity can provide (for example reduced risk of type 2 diabetes and cardiovascular disease) [NICE, 2006b].
NICE have also produced a public health guidance entitled 'Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers, and community-based exercise programmes for walking and cycling' which can be accessed at www.nice.org.uk [NICE, 2006a].
Scenario : BMI 30-34.9 (obesity I)
Scenario : BMI 30-34.9 kg/m2 (obesity I)
Approach to managing weight
How should I approach managing a person's weight?
Aim to help the person increase their physical activity levels and improve their diet and eating behaviour.
Consider the use of behavioural intervention to achieve this aim.
When deciding on treatment type, consider the person's:
Preferences.
Degree of overweight or obesity.
Level of risk (using body mass index and waist circumference, if appropriate).
Comorbidities.
Social circumstances.
Previous treatments.
The person's level of risk and their potential for health benefits from weight loss should be considered when deciding on the intensity of intervention.
Base weight loss targets on the person's co-morbidities and risks, rather than weight alone.
Aim for an overall 5–10% reduction in body weight (higher in people with BMI greater than 35 kg/m2).
Weekly weight loss should be no more than 1 kg.
The person should be given a copy of their main goals, according to their needs.
Offer a level of support appropriate to the person's needs.
Offer encouragement and praise for successes, however small.
Discuss the importance of developing skills for maintaining weight loss.
If a person declines intervention, offer them the opportunity to make contact in the future for support and advice if they change their mind.
Behavioural interventions
Behavioural interventions
Any behavioural intervention should be delivered with the support of an appropriately trained professional.
Behavioural interventions for adults should include the following strategies, as appropriate for the person:
Self monitoring of behaviour and progress
Stimulus control
Goal setting
Slowing rate of eating
Ensuring social support
Problem solving
Assertiveness
Cognitive restructuring (modifying thoughts)
Reinforcement of changes
Relapse prevention
Strategies for dealing with weight regain
The level of behavioural intervention will depend on the availability of local resources.
Basis for recommendation
Basis for recommendation
This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
Targets for weight loss
In people with BMI 25–35 kg/m2, a 5-10% weight loss (approximately 5–10 kg) is required to produce a clinically significant reduction in cardiovascular disease and metabolic risk.
In those with a BMI greater than 35 kg/m2, obesity-related co-morbidities are already likely to exist, and a greater weight reduction may be required (15–20%) to obtain a sustained improvement in comorbidity.
Managing when BMI 30-34.9 (obesity I)
How should I manage someone with a BMI 30-34.9 (obesity I)?
Offer structured advice regarding diet and physical activity.
Consider starting drug treatment with orlistat in people with body mass index (BMI) 30 kg/m2 or greater.
Drug treatment should only be considered once dietary and physical activity interventions have been evaluated.
Drug treatment should form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.
Basis for recommendation
Basis for recommendation
Recommendations for the level of intervention in someone with a body mass index between 30 and 34.9 kg/m2 are based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the manufacturer's Summary of Product Characteristics for Xenical® [ABPI Medicines Compendium, 2012].
There is good evidence that orlistat is effective in improving weight loss compared with placebo. After 12 months the median weight loss with orlistat (in combination with a weight-reducing diet) was 5.4 kg (range 3.3 to 7.6 kg).
Dietary advice
What advice should I give about diet?
Advice on dietary changes should take into account the person's food preferences and allow for flexible approaches to reducing calorie intake. The 'Your Weight, Your Health' booklet available from the Department of Health website, www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses diet as part of a healthy life.
Promote a diet which is in line with healthy eating recommendations, is acceptable to the person, and is sustainable in the long term.
Ensure that the person is aware of the changes they will need to make to their usual eating habits.
All healthy people over 5 years old should eat a balanced diet rich in fruit, vegetables, and starchy foods including:
Five portions of a variety of types of fruit and vegetables each day.
Meals based on starchy foods (for example bread, pasta, rice, and potatoes) — include high fibre varieties if possible.
Moderate amounts of milk and dairy products — should be low fat if possible.
Moderate amounts of protein-rich foods (for example meat, fish, eggs, beans, and lentils).
A reduction in the amounts of foods high in fat (especially saturated fat), sugar, and salt.
A reduction in alcohol intake (alcohol is high in calories).
Cooking using methods which reduce fat (for example grilling, steaming).
People should be encouraged to improve their diet even if they do not lose weight.
Diets that are recommended for sustainable weight loss in combination with expert support and intensive follow up are:
Those with a 600 kcal/day deficit (i.e. they contain 600 kcal less than the person needs to stay the same weight), or
Those which reduce calories by lowering the fat content (low-fat diets).
Low-calorie diets (1000–1600 kcal/day) are less likely to be nutritionally complete, but can be considered in combination with expert support and intensive follow up.
Very-low-calorie diets (less than 1000 kcal/day) may be used, under specialist clinical supervision, for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), if a person is obese and has reached a plateau in weight loss.
Any diet of less than 600 kcal/day should be used only under specialist clinical supervision.
In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.
Do not use unduly restrictive and nutritionally unbalanced diets.
Basis for recommendation
Basis for recommendation
This recommendation is based the National Institute for Health and Clinical Excellence guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the associated NICE quick reference guide [NICE, 2006c]. Recommendations for healthy eating are based on the Balance of Good Health from the Food Standards Agency [DH, 2006; National Heart Forum, 2007].
There is evidence to suggest that dietary interventions in people with overweight or obesity are effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful [NICE, 2006b].
People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits [NICE, 2006b].
Advice about physical activity
What advice should I give about physical activity?
Any advice given about exercise activities and duration should consider the person's current physical fitness and ability. If appropriate, encourage the person to:
Reduce the amount of time they spend being inactive (for example watching television).
Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (in one session, or split into a number of sessions).
Build up to the recommended levels for weight maintenance, using a managed approach with agreed goals.
Recommended types of physical activity include:
Activities that can be incorporated into everyday life, for example brisk walking, gardening, or cycling.
Supervised exercise programmes.
Other activities (for example swimming or stair climbing).
A pedometer may be useful for motivation and to help a person monitor their activity levels. If appropriate, adults can gradually work towards a goal of 10,000 steps a day.
The 'Your Weight, Your Health' booklet available from the Department of Health website www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses incorporating exercise into a healthy life.
Encourage the person to take more exercise even if it does not lead to weight loss because it has other health benefits, such as reducing the risk of type 2 diabetes and cardiovascular disease.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
There is evidence to suggest that physical activity in people with overweight or obesity is effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Adults should be encouraged to increase their physical activity even if it does not result in weight loss, because of the other health benefits physical activity can provide (for example reduced risk of type 2 diabetes and cardiovascular disease) [NICE, 2006b].
NICE have also produced a public health guidance entitled 'Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers, and community-based exercise programmes for walking and cycling' which can be accessed at www.nice.org.uk [NICE, 2006a].
Scenario : BMI 35-39.9 (obesity II)
Scenario : BMI 35-39.9 kg/m2 (obesity II)
Approach to managing weight
How should I approach managing a person's weight?
Aim to help the person increase their physical activity levels and improve their diet and eating behaviour.
Consider the use of behavioural interventions to achieve this aim.
When deciding on treatment type, consider the person's:
Preferences.
Degree of overweight or obesity.
Level of risk (using body mass index and waist circumference, if appropriate).
Comorbidities.
Social circumstances.
Previous treatments.
The person's level of risk and their potential for health benefits from weight loss should be considered when deciding on the intensity of intervention.
Base weight loss targets on the person's co-morbidities and risks, rather than weight alone.
Aim for an overall 5–10% reduction in body weight (higher in people with BMI greater than 35 kg/m2).
Weekly weight loss should be no more than 1 kg.
The person should be given a copy of their main goals, according to their needs.
Offer a level of support appropriate to the person's needs.
Offer encouragement and praise for successes, however small.
Discuss the importance of developing skills for maintaining weight loss.
If a person declines intervention, offer them the opportunity to make contact in the future for support and advice if they change their mind.
Behavioural interventions
Behavioural interventions
Any behavioural intervention should be delivered with the support of an appropriately trained professional.
Behavioural interventions for adults should include the following strategies, as appropriate for the person:
Self monitoring of behaviour and progress
Stimulus control
Goal setting
Slowing rate of eating
Ensuring social support
Problem solving
Assertiveness
Cognitive restructuring (modifying thoughts)
Reinforcement of changes
Relapse prevention
Strategies for dealing with weight regain
The level of behavioural intervention will depend on the availability of local resources.
Basis for recommendation
Basis for recommendation
This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the Scottish Intercollegiate Guidelines Network (SIGN) guideline, Management of Obesity [SIGN, 2010].
Targets for weight loss
In people with BMI 25–35 kg/m2, a 5-10% weight loss (approximately 5–10 kg) is required to produce a clinically significant reduction in cardiovascular disease and metabolic risk.
In those with a BMI greater than 35 kg/m2, obesity-related co-morbidities are already likely to exist, and a greater weight reduction may be required (15–20%) to obtain a sustained improvement in comorbidity.
Managing when BMI 35-39.9 (obesity II)
How should I manage someone with a BMI 35-39.9 (obesity II)
Offer structured advice regarding diet and physical activity.
Consider starting drug treatment with orlistat once dietary and physical activity interventions have been evaluated.
Drug treatment should form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.
Consider referral for surgery. Bariatric surgery is recommended as a treatment option if all of the following criteria are fulfilled:
The person has a body mass index between 35 kg/m2 and 40 kg/m2 and other significant disease (for example type 2 diabetes, hypertension, severe mobility problems) that could be improved if they lost weight.
All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
The person is receiving, or will receive, intensive specialist management.
The person is generally fit for anaesthesia and surgery.
The person commits to the need for long-term follow up.
Local criteria and policies on access to bariatric surgery may vary. Usually referral for surgery will be made via a specialist obesity management service.
Basis for recommendation
Basis for recommendation
Recommendations for the level of intervention in someone with a body mass index between 35 and 39.9 kg/m2 are from the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [NICE, 2006b].
There is good evidence that orlistat is effective in improving weight loss compared with placebo [NICE, 2006b]. After 12 months the median weight loss with orlistat (in combination with a weight-reducing diet) was 5.4 kg (range 3.3 to 7.6 kg).
Evidence from a Cochrane systematic review [Colquitt et al, 2009]and a Health Technology Assessment [Picot et al, 2009] indicates that bariatric surgery is more effective for weight loss than non-surgical options.
In two randomized controlled trials (RCTs), the mean initial weight loss at 2 years in the surgical groups was 20.0% and 21.6%, compared with 1.4% and 5.5% in the non-surgical groups.
In two cohort studies, the percentage weight loss at 2 years in the surgical groups ranged from 16.0% to and 28.6%, compared with a weight gain of 0.1% to 0.5% in the non-surgical groups.
One RCT and two cohort studies found greater improvements in some, but not all, quality of life measures.
One large cohort study also found a significant reduction in the incidence of three out of six comorbidities assessed at 10 years after surgery compared with conventional treatment.
Dietary advice
What advice should I give about diet?
Advice on dietary changes should take into account the person's food preferences and allow for flexible approaches to reducing calorie intake. The 'Your Weight, Your Health' booklet available from the Department of Health website, www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses diet as part of a healthy life.
Promote a diet which is in line with healthy eating recommendations, is acceptable to the person, and is sustainable in the long term.
Ensure that the person is aware of the changes they will need to make to their usual eating habits.
All healthy people over 5 years old should eat a balanced diet rich in fruit, vegetables, and starchy foods including:
Five portions of a variety of types of fruit and vegetables each day.
Meals based on starchy foods (for example bread, pasta, rice, and potatoes) — include high fibre varieties if possible.
Moderate amounts of milk and dairy products — should be low fat if possible.
Moderate amounts of protein-rich foods (for example meat, fish, eggs, beans, and lentils).
A reduction in the amounts of foods high in fat (especially saturated fat), sugar, and salt.
A reduction in alcohol intake (alcohol is high in calories).
Cooking using methods which reduce fat (for example grilling, steaming).
People should be encouraged to improve their diet even if they do not lose weight.
Diets that are recommended for sustainable weight loss in combination with expert support and intensive follow up are:
Those with a 600 kcal/day deficit (i.e. they contain 600 kcal less than the person needs to stay the same weight), or
Those which reduce calories by lowering the fat content (low-fat diets).
Low-calorie diets (1000–1600 kcal/day) are less likely to be nutritionally complete, but can be considered in combination with expert support and intensive follow up.
Very-low-calorie diets (less than 1000 kcal/day) may be used, under specialist clinical supervision, for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), if a person is obese and has reached a plateau in weight loss.
Any diet of less than 600 kcal/day should be used only under specialist clinical supervision.
In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.
Do not use unduly restrictive and nutritionally unbalanced diets.
Basis for recommendation
Basis for recommendation
This recommendation is based on guidance from the National Institute for Health and Clinical Excellence on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the associated NICE quick reference guide [NICE, 2006c]. Recommendations for healthy eating are based on the Balance of Good Health from the Food Standards Agency [DH, 2006; National Heart Forum, 2007].
There is evidence to suggest that dietary interventions in people with overweight or obesity are effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful [NICE, 2006b].
People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits [NICE, 2006b].
Advice about physical activity
What advice should I give about physical activity?
Any advice given about exercise activities and duration should consider the person's current physical fitness and ability. If appropriate, encourage the person to:
Reduce the amount of time they spend being inactive (for example watching television).
Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (in one session, or split into a number of sessions).
Build up to the recommended levels for weight maintenance, using a managed approach with agreed goals.
Recommended types of physical activity include:
Activities that can be incorporated into everyday life, for example brisk walking, gardening, or cycling.
Supervised exercise programmes.
Other activities (for example swimming or stair climbing).
A pedometer may be useful for motivation and to help a person monitor their activity levels. If appropriate, adults can gradually work towards a goal of 10,000 steps a day.
The 'Your Weight, Your Health' booklet available from the Department of Health website www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses incorporating exercise into a healthy life.
Encourage the person to take more exercise even if it does not lead to weight loss because it has other health benefits, such as reducing the risk of type 2 diabetes and cardiovascular disease.
Basis for recommendation
Basis for recommendation
This recommendation is based on guidance from the National Institute for Health and Clinical Excellence (NICE) on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
There is evidence to suggest that physical activity in people with overweight or obesity is effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Adults should be encouraged to increase their physical activity even if it does not result in weight loss, because of the other health benefits physical activity can provide (for example reduced risk of type 2 diabetes and cardiovascular disease) [NICE, 2006b].
NICE have also produced a public health guidance entitled 'Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers, and community-based exercise programmes for walking and cycling' which can be accessed at www.nice.org.uk [NICE, 2006a].
Scenario : BMI >= 40 (obesity III)
Scenario : BMI >= 40 kg/m2 (obesity III)
Approach to managing weight
How should I approach managing a person's weight?
Aim to help the person increase their physical activity levels and improve their diet and eating behaviour.
Consider the use of behavioural interventions to achieve this aim.
When deciding on treatment type, consider the person's:
Preferences.
Degree of overweight or obesity.
Level of risk (using body mass index and waist circumference, if appropriate).
Comorbidities.
Social circumstances.
Previous treatments.
The person's level of risk and their potential for health benefits from weight loss should be considered when deciding on the intensity of intervention.
Base weight loss targets on the person's co-morbidities and risks, rather than weight alone.
Aim for an overall 5–10% reduction in body weight (higher in people with BMI greater than 35 kg/m2).
Weekly weight loss should be no more than 1 kg.
The person should be given a copy of their main goals, according to their needs.
Offer a level of support appropriate to the person's needs.
Offer encouragement and praise for successes, however small.
Discuss the importance of developing skills for maintaining weight loss.
If a person declines intervention, offer them the opportunity to make contact in the future for support and advice if they change their mind.
Behavioural interventions
Behavioural interventions
Any behavioural intervention should be delivered with the support of an appropriately trained professional.
Behavioural interventions for adults should include the following strategies, as appropriate for the person:
Self monitoring of behaviour and progress
Stimulus control
Goal setting
Slowing rate of eating
Ensuring social support
Problem solving
Assertiveness
Cognitive restructuring (modifying thoughts)
Reinforcement of changes
Relapse prevention
Strategies for dealing with weight regain
The level of behavioural intervention will depend on the availability of local resources.
Basis for recommendation
Basis for recommendation
This recommendation is based the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the Scottish Intercollegiate Guidelines Network (SIGN) guideline, Management of Obesity [SIGN, 2010].
Targets for weight loss
In people with BMI 25–35 kg/m2, a 5-10% weight loss (approximately 5–10 kg) is required to produce a clinically significant reduction in cardiovascular disease and metabolic risk.
In those with a BMI greater than 35 kg/m2, obesity-related co-morbidities are already likely to exist, and a greater weight reduction may be required (15–20%) to obtain a sustained improvement in comorbidity.
Managing when BMI >= 40 (obesity III)
How should I manage someone with a BMI >= 40 (obesity III)
Offer structured advice regarding diet and physical activity.
This may be via a specialised weight management programme where available.
Consider starting drug treatment with orlistat once dietary and physical activity interventions have been evaluated.
Drug treatment should form part of an integrated approach to weight management, which should include advice, support, counselling on diet and physical activity, and behavioural strategies.
Consider referral for surgery. Bariatric surgery is recommended as a treatment option if all of the following criteria are fulfilled:
The person has a body mass index (BMI) equal to or greater than 40 kg/m2.
All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
The person is receiving, or will receive, intensive specialist management.
The person is generally fit for anaesthesia and surgery.
The person commits to the need for long-term follow up.
Consider surgery as a first-line option in adults with a BMI greater than 50 kg/m2 in whom surgical intervention is considered appropriate.
Orlistat should be considered whilst the person is waiting for surgery.
Local criteria and policies on access to bariatric surgery may vary. Usually referral for surgery will be made via a specialist obesity management service.
Basis for recommendation
Basis for recommendation
Recommendations for the level of intervention in someone with a BMI greater than or equal to 40 kg/m2 are from the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
There is good evidence that orlistat is effective in improving weight loss compared with placebo [NICE, 2006b]. After 12 months the median weight loss with orlistat (in combination with a weight-reducing diet) was 5.4 kg (range 3.3 to 7.6 kg).
Evidence from a Cochrane systematic review [Colquitt et al, 2009] and a Health Technology Assessment [Picot et al, 2009] indicates that bariatric surgery is more effective for weight loss than non-surgical options.
In two randomized controlled trials (RCTs), the mean initial weight loss at 2 years in the surgical groups was 20.0% and 21.6%, compared with 1.4% and 5.5% in the non-surgical groups.
In two cohort studies, the percentage weight loss at 2 years in the surgical group ranged from 16.0% to 28.6%, compared with a weight gain of 0.1% to 0.5% in the non-surgical groups.
One RCT and two cohort studies found greater improvements in some, but not all, quality of life measures.
One large cohort study also found a significant reduction in the incidence of three out of six comorbidities assessed at 10 years after surgery compared with conventional treatment.
Dietary advice
What advice should I give about diet?
Take into account the person's food preferences and allow for flexible approaches to reducing calorie intake. The 'Your Weight, Your Health' booklet available from the Department of Health website, www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses diet as part of a healthy life.
Promote a diet which is in line with healthy eating recommendations, is acceptable to the person, and is sustainable in the long term.
Ensure that the person is aware of the changes they will need to make to their usual eating habits.
All healthy people over 5 years old should eat a balanced diet rich in fruit, vegetables and starchy foods.
Encourage the person to improve their diet even if they do not lose weight.
Diets that are recommended for sustainable weight loss in combination with expert support and intensive follow up are:
Those with a 600 kcal/day deficit (i.e. they contain 600 kcal less than the person needs to stay the same weight), or
Those which reduce calories by lowering the fat content (low-fat diets).
Low-calorie diets (1000–1600 kcal/day) are less likely to be nutritionally complete, but can be considered with expert support and intensive follow up.
Very-low-calorie diets (less than 1000 kcal/day) may be used, under specialist clinical supervision, for a maximum of 12 weeks continuously, or intermittently with a low-calorie diet (for example for 2–4 days a week), if a person is obese and has reached a plateau in weight loss.
Any diet of less than 600 kcal/day should be used only under specialist clinical supervision.
In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.
Do not use unduly restrictive and nutritionally unbalanced diets.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b] and the associated NICE quick reference guide [NICE, 2006c]. Recommendations for healthy eating are based on the Balance of Good Health from the Food Standards Agency [DH, 2006; National Heart Forum, 2007].
There is evidence to suggest that dietary interventions in people with overweight or obesity are effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful [NICE, 2006b].
People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits [NICE, 2006b].
Advice about physical activity
What advice should I give about physical activity?
Any advice given about exercise activities and duration should consider the person's current physical fitness and ability. If appropriate, encourage the person to:
Reduce the amount of time they spend being inactive (for example watching television).
Do at least 30 minutes of at least moderate intensity exercise on 5 days a week or more (in one session, or split into a number of sessions).
Build up to the recommended levels for weight maintenance, using a managed approach with agreed goals.
Recommended types of physical activity include:
Activities that can be incorporated into everyday life, for example brisk walking, gardening, or cycling.
Supervised exercise programmes.
Other activities (for example swimming or stair climbing).
A pedometer may be useful for motivation and to help a person monitor their activity levels. If appropriate, adults can gradually work towards a goal of 10,000 steps a day.
The 'Your Weight, Your Health' booklet available from the Department of Health website www.dh.gov.uk is aimed at people who are ready to address their weight, and discusses incorporating exercise into a healthy life.
Encourage the person to take more exercise even if it does not lead to weight loss because it has other health benefits, such as reducing the risk of type 2 diabetes and cardiovascular disease.
Basis for recommendation
Basis for recommendation
This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline, Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children [NICE, 2006b].
There is evidence to suggest that physical activity in people with overweight or obesity is effective in terms of weight loss, and that this effectiveness is increased when dietary interventions are combined with physical activity [National Collaborating Centre for Primary Care, 2006].
Adults should be encouraged to increase their physical activity even if it does not result in weight loss, because of the other health benefits physical activity can provide (for example reduced risk of type 2 diabetes and cardiovascular disease) [NICE, 2006b].
NICE have also produced a public health guidance entitled 'Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers, and community-based exercise programmes for walking and cycling' which can be accessed at www.nice.org.uk [NICE, 2006a].
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Orlistat
Orlistat is a pancreatic lipase inhibitor that inhibits triglyceride digestion and reduces fat absorption [ABPI Medicines Compendium, 2012].
Criteria for starting orlistat
What are the criteria for starting orlistat?
Orlistat is licensed in conjunction with a mildly hypocaloric diet for adults aged between 18 and 75 years who meet one of the following criteria:
Obese with a body mass index (BMI) greater than or equal to 30 kg/m2, or
Overweight with a BMI greater than or equal to 28 kg/m2 with associated risk factors.
Contraindications
Who should avoid taking orlistat?
Because it reduces the absorption of dietary fat, orlistat should not be prescribed for anyone with a chronic malabsorption syndrome or cholestasis, as dietary absorption of fat is already impaired [ABPI Medicines Compendium, 2012].
Adverse effects
What adverse effects are associated with orlistat?
Gastrointestinal adverse effects are common (for example oily spotting, abdominal discomfort, faecal urgency, fatty stools). These usually reduce with continued use of orlistat and can often be reduced by limiting fat intake [ABPI Medicines Compendium, 2012].
Absorption of fat-soluble vitamins (A, D, E, K, and beta-carotene) may be impaired in people taking orlistat, however, in most people levels remain within the normal range [ABPI Medicines Compendium, 2012].
Advise people to have a diet that is rich in fruit and vegetables and consider the use of a multivitamin supplement.
Multivitamin supplements should be taken at least two hours after taking orlistat.
Very rarely (< 1/10,000) hepatitis and cholelithiasis have been reported [MHRA, 2010].
The European Medicines Agency has recently reviewed the safety of orlistat, following concerns about the possible risk of hepatic injury and concluded that the benefits of orlistat outweigh the risks [EMA, 2012].
Duration of treatment
For how long should treatment with orlistat continue?
Treatment with orlistat should only continue beyond 3 months if the person has lost at least 5% of their body weight, as measured at the start of drug treatment [NICE, 2006b; ABPI Medicines Compendium, 2012].
Rates of weight loss may be slower in people with type 2 diabetes, so less strict goals may be appropriate. These goals should be agreed with the person and reviewed regularly.
There is no restriction on how long orlistat may be prescribed [ABPI Medicines Compendium, 2012].
Expert opinion is that, after 12 months, a decision to continue treatment should be taken on an individual basis, weighing up the benefits, costs, and risks for that person. This should be reviewed at regular intervals.
Important interactions
What important interactions are associated with orlistat?
If fat-soluble vitamins or multivitamin supplements are taken, they should be given at least 2 hours after a dose of orlistat or at bedtime.
Orlistat reduces plasma levels of ciclosporin. If concomitant use is unavoidable, ciclosporin levels should be monitored frequently, both after initiation of orlistat and on discontinuation [Baxter, 2010].
Orlistat may reduce the absorption of levothyroxine, leading to reduced control of hypothyroidism [MHRA, 2010]. Consider taking levothyroxine at a different time to orlistat to reduce the interaction (such as 2 hours after a dose of orlistat or at bedtime).
Orlistat may also reduce the absorption of antiepileptic drugs. Loss of seizure control has been reported during concomitant treatment with orlistat and sodium valproate or lamotrigine [MHRA, 2010]. Consider taking antiepileptic drugs at a different time to orlistat to reduce the interaction (such as 2 hours after a dose of orlistat or at bedtime).
Orlistat may reduce the absorption of fat-soluble vitamin K, with the result that a lower dose of warfarin is required. In people taking warfarin, the international normalized ratio (INR) should be monitored closely, especially when starting or stopping treatment with orlistat [Baxter, 2010].
No direct interaction between oral contraceptives and orlistat has been demonstrated in specific drug-drug interaction studies. However, orlistat may indirectly reduce the availability of oral contraceptives through its action on the gastrointestinal tract. If a woman experiences severe diarrhoea whilst taking orlistat an additional contraceptive method is recommended [ABPI Medicines Compendium, 2012].
Advice for patients
What advice should I give to someone who has been prescribed orlistat?
Orlistat 120 mg should be taken immediately before, during, or up to 1 hour after each main meal (up to a maximum of three times a day).
The dose of orlistat should be omitted if a meal is missed, or if the meal contains little or no fat.
[ABPI Medicines Compendium, 2012]
People taking orlistat should be informed of the symptoms of hepatitis (yellowing skin and eyes, itching, dark-coloured urine, stomach pain and liver tenderness), and advised to stop taking orlistat and seek medical assistance if they develop any of these symptoms [EMA, 2012].
Roche provide a support service for people who have been prescribed orlistat. Details for registration are provided with the drug packaging.
Pregnancy and breastfeeding
Can orlistat be used during pregnancy and breastfeeding?
Orlistat may be used with caution during pregnancy.
The use of weight-loss medications during pregnancy is not generally recommended because they may interfere with adequate nutrition for both the woman and the fetus.
No clinical data on pregnancies exposed to orlistat are available. The potential effects on the fetus are unknown. Studies in animals do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/fetal development, parturition, or postnatal development.
Orlistat is contraindicated during breastfeeding.
It is not known whether orlistat is secreted into human milk.
Evidence
Evidence
Supporting evidence
Clinical assessment
Evidence on clinical assessment of adults who are overweight or obese
The National Institute for Health and Clinical Excellence considered recommendations from a number of guidelines on the assessment of adults and mature adolescents with overweight or obesity and concluded [National Collaborating Centre for Primary Care, 2006]:
Initial assessment should aim to identify individuals at highest risk, who have the potential to gain health benefits with weight loss and maintenance of that weight loss.
In adults who are overweight and obese, individuals at highest risk and with the potential to gain health benefits include those with current significant comorbidities, and those at high risk of developing significant comorbidities in the future.
In adults, reasons for energy imbalance are environment, genes, stress and psychological factors, current medication, life stage (early childhood and adolescence, pregnancy and childbirth, menopause), and life events (stopping smoking, marriage, giving up sport, holidays).
Diet
Evidence on diet to treat overweight and obesity
Evidence suggests that specific dietary interventions (600 kcal-deficit diet, low-fat diet, low-calorie diet, and very-low calorie diet) are more effective at achieving weight loss than usual care. There is insufficient evidence to state which type of diet is most effective.
A National Institute for Health and Clinical Excellence (NICE) evidence review [National Collaborating Centre for Primary Care, 2006] was primarily based on a health technology appraisal (HTA) published in 2004 [Avenell et al, 2004b].
Randomized controlled trials (RCTs) of dietary interventions in adults with a body mass index (BMI) of greater than 28 kg/m2, with duration of 52 weeks or more, were included in the HTA review.
The NICE evidence review found:
600 kcal deficit diet or low fat diet compared with usual care:
A 600 kcal-deficit diet or low fat diet was effective, resulting in a body weight change of around –5 kg (95% CI –5.86 to –4.75) compared with usual care, after 1 year (12 studies).
Low-calorie diet compared with usual care:
A low-calorie diet of 1000–1600 kcal/day was effective, resulting in a body weight change of around –6 kg (95% CI –9.05 to –3.24) compared with usual care, after 1 year (2 studies).
Very-low-calorie diet compared with usual care:
A very-low-calorie diet (VLCD) (420 kcal/day for 8 weeks) was shown in one study to cause significant weight loss, resulting in a body weight change of –13.40 kg (95% CI –18.43 to –8.37) compared with usual care, after 1 year.
Low-calorie diet compared with 600 kcal deficit diet or low fat diet:
A low-calorie diet was equally effective as a 600 kcal deficit diet or low fat diet, resulting in a body weight change of around +1 kg (95% CI –1.06 to +2.63) compared with usual care, at 12 months (2 studies).
VLCD compared with 600 kcal deficit diet or low fat diet:
A VLCD (420 kcal/day for 12 weeks) was shown in one study to result in a non significant body weight change of –4.70 kg (95% CI –11.79 to +2.39) compared with a 600 kcal deficit diet or low fat diet, at 24 months.
VLCD in conjunction with low-calorie diet, compared with continuous low-calorie diet:
An 800 kcal/day VLCD, used for 4 days a week with a 1200 kcal diet for 3 days a week, in one study, was as effective as a continuous low-calorie diet, resulting in a body weight change of around 0 kg (range +3.53 to –3.56 kg) compared with a low-calorie diet, at 12 months (1 study).
A 750 kcal/day VLCD used for 2 days a week with a low-calorie diet (body weight in pounds x 12 – 1000 kcal) on the other days was as effective as a continuous low-calorie diet, resulting in a body weight change of around 0 kg (range +2.11 to –2.33 kg) compared with a low-calorie diet, at 12 months (2 comparisons from one study).
An 800 kcal/day VLCD for 8 weeks was as effective as a continuous low-calorie diet (kcal not specified) for 8 weeks, resulting in a body weight change of 1.13 kg (range +3.06 to –5.32 kg) compared with a low-calorie diet, at 18 months (2 comparisons from one study).
Low fat diet compared with other diets with the same calorie content:
A low fat diet was as effective as other diets, resulting in a body weight change of around 0.5 kg (95% CI –1.14 to +2.11) compared with other diets, at 12 months.
Low-calorie diet compared with very-low-fat diet:
A low-calorie diet was found in one study to cause a non-significant weight change of +0.30 kg (95% CI –2.42 to +3.02) compared with a very-low-fat diet, at 12 months.
No evidence statements were made regarding harms or adverse effects.
There was insufficient evidence to compare the use of diets in people with specific comorbidities.
For a discussion of dietary interventions compared with physical activity, and dietary interventions combined with physical activity, see Physical activity.
Physical activity
Evidence on physical activity to treat overweight and obesity
Evidence suggests that for people who are overweight or obese, physical activity is effective in terms of weight loss over 1 year, and that combining physical activity with dietary interventions over the same time period results in a greater amount of weight lost.
A National Institute for Health and Clinical Excellence (NICE) evidence review [National Collaborating Centre for Primary Care, 2006] was based on three key reviews: a health technology appraisal (HTA) published in 2004 [Avenell et al, 2004b], a Cochrane review of exercise for overweight or obesity [Shaw et al, 2006], and a summary of evidence on screening and interventions for obesity [McTigue et al, 2003].
NICE found:
Physical activity compared with no treatment:
Physical activity for a minimum of 30 minutes three times a week was effective, resulting in a body weight change of around –3 kg (95% CI –4.00 to –2.18) compared with no treatment, at 12 months (3 studies).
Physical activity compared with information:
Physical activity for 60 minutes three times a week was shown in one study to cause a change in body weight of –2.36 kg (95% CI –4.41 to –0.31) compared with information, at 18 months.
Physical activity alone compared with diet alone:
Physical activity alone for a minimum of 30 minutes three times a week was less effective than diet alone, resulting in a body weight change of +3 kg (95% CI 2.28 to 4.35) at 12 months. For physical activity, median body weight change was around –2.60 kg (range –0.90 to –4.00 kg) and for diet alone, –6.40 kg (range –4.00 to –7.20 kg) (3 studies).
Physical activity and diet compared with no treatment:
Physical activity for a minimum of 45 minutes three times a week and a 600 kcal deficit or low-fat diet was effective, resulting in a body weight change of around –7 kg (95% CI –7.88 to –5.87) compared with no treatment, at 12 months (5 studies).
Physical activity and diet compared with diet alone:
A minimum of 45 minutes physical activity three times a week and a 600 kcal deficit or low fat diet was effective, resulting in a body weight change of around –1.95 kg (95% CI –3.22 to –0.68) compared with diet alone, at 12 months (5 studies).
Physical activity plus behaviour therapy and diet compared with no treatment:
Various levels of physical activity, behaviour therapy in different forms, and either a low-calorie or calorie-deficit diet was effective, resulting in a body weight change of –4.22 kg (95% CI –4.80 to –3.64) compared with no treatment, at 12 months (5 studies).
Physical activity plus behaviour therapy and diet compared with information alone:
Various levels of physical activity, behaviour therapy in different forms, and either a very-low-calorie or calorie-deficit diet was effective, resulting in a body weight change of –3.82 kg (95% CI –4.63 to –3.02) compared with information alone (6 studies).
Physical activity, behaviour therapy, and calorie-deficit diet compared with behaviour therapy alone:
In one trial, the combination treatment was associated with an absolute body weight change of –5.90 kg for the combined group, compared with –0.10 kg for the behaviour therapy group.
Physical activity, behaviour therapy, and very-low-calorie diet compared with physical activity and behaviour therapy:
In one trial, the combination treatment was associated with an absolute body weight change of –7.4 kg compared with –0.4 kg for physical activity and behaviour therapy.
No statement was made on the evidence for harms and adverse effects.
No statement on the different levels of exercise intensity could be made.
Orlistat
Evidence on orlistat
Evidence from two systematic reviews shows that, in combination with a weight-reducing diet, orlistat produces significantly greater weight loss than placebo after 12, 24, and 48 months of treatment. This change is in the magnitude of 4.2 to 5.8 kg. In people with type 2 diabetes the weight loss seen with orlistat is less (approximately 3.9 kg after 1 year). In addition orlistat significantly improves lipid profile and blood pressure compared with placebo, although the clinical significance of the actual changes in these parameters is small. When continued for 4 years, the risk of developing type 2 diabetes is reduced by 37% in people taking orlistat compared with those taking placebo.
The National Institute for Health and Clinical Excellence (NICE) evidence review on orlistat (search date December 2005) identified two key systematic reviews of orlistat [O'Meara et al, 2001; Avenell et al, 2004a]. Only randomized controlled trials (RCTs) with a duration of 12 months or more (including follow up) were included, and all study participants had to have a body mass index (BMI) of at least 28 kg/m2.
Sixteen RCTs were identified that compared orlistat (120 mg three times a day) in combination with a weight-reducing diet with placebo plus diet.
Overall weight loss:
At 12 months (15 studies) there was significantly greater weight loss in people taking orlistat compared with placebo (difference in weight loss = 3.3 kg, 95% CI 3.0 to 3.6). Median weight loss with orlistat was 5.4 kg (range 3.3 to 7.6 kg).
At 24 months (2 studies) there was significantly greater weight loss in people taking orlistat compared with placebo (difference in weight loss = 3.26 kg, 95% CI 2.37 to 4.15). Median weight loss with orlistat was 4.2 kg (range 2.5 to 6.0 kg).
At 48 months (1 study) there was significantly greater weight loss in people taking orlistat compared with placebo (difference in weight loss = 2.80 kg, 95% CI 2.31 to 3.29). Absolute weight loss with orlistat was 5.8 kg.
Weight regain:
After an initial 12 months of treatment with orlistat, people who continued taking orlistat for a further 12 months regained significantly less weight than those who continued taking placebo for a further 12 months (3.2 kg vs. 5.6 kg, p < 0.001).
Lipids:
At 12 months there was a significantly greater decrease in total cholesterol (TC) (12 studies) in all people taking orlistat compared with those taking placebo (difference in TC = 0.36 mmol/L, 95% CI 0.31 to 0.40). Median change in TC was –0.21 mmol/L (range –0.51 to +0.03 mmol/L).
There was a significantly greater decrease in low density lipoprotein-cholesterol (12 studies) in all people taking orlistat compared with those taking placebo (difference in LDL-C = 0.30 mmol/L, 95% CI 0.27 to 0.33).
There was a small but significantly greater increase in high density lipoprotein-cholesterol (10 studies) in all people taking orlistat compared with those taking placebo (difference in HDL-C = 0.04 mmol/L, 95% CI 0.03 to 0.05).
Blood pressure:
There were significantly greater decreases in diastolic blood pressure (DBP) (12 studies) and systolic blood pressure (SBP) (13 studies) in people taking orlistat compared with those taking placebo (DBP: 1.42 mmHg, 95% CI 1.05 to 1.80; SBP: 1.98 mmHg, 95% CI 1.42 to 2.54).
Progression to type 2 diabetes:
In one study (n = 3277), during 4 years of treatment orlistat plus lifestyle changes significantly decreased the progression to type 2 diabetes compared with placebo plus lifestyle changes (p = 0.0032). Cumulative incidence rates after 4 years were 6.2 vs. 9.0%). The risk of developing type 2 diabetes was 37% lower with orlistat plus lifestyle changes compared with placebo plus lifestyle changes.
People with type 2 diabetes:
Three studies investigated the effects of orlistat (120 mg three times a day) over 12 months in people with type 2 diabetes.
There was significantly greater weight loss in people taking orlistat compared with placebo (difference in weight loss = 2.7 kg, 95% CI 2.2 to 3.2). Median weight loss with orlistat was 3.9 kg (range 3.8 to 4.7 kg).
There was a significantly greater decrease in TC in people taking orlistat compared with those taking placebo (0.40 mmol/L, 95% CI 0.30 to 0.50). Median change in TC with orlistat was –0.27 mmol/L (range –0.30 to –0.05 mmol/L).
There was a significantly greater decrease in glycosylated haemoglobin (HbA1c) in people taking orlistat compared with those taking placebo (difference in HbA1c = 0.36%, 95% CI 0.28 to 0.45). Median change in HbA1c with orlistat was –0.62% (range –0.75 to –0.15%).
There was a significantly greater decrease in fasting plasma glucose (FPG) in people taking orlistat compared with those taking placebo (difference in FPG = 0.84 mmol/L, 95% CI 0.64 to 1.04). Median change in FPG with orlistat was –1.63 mmol/L (range –2.00 to +0.04 mmol/L).
There were significantly greater decreases in diastolic blood pressure (2 studies) and systolic blood pressure (3 studies) in people taking orlistat compared with those taking placebo (difference in DBP: 1.28 mmHg, 95% CI 0.15 to 2.4; difference in SBP: 1.62 mmHg, 95% CI 0.25 to 2.99). Median change for DBP was –1.70 mmHg (range –2.30 to –1.01 mmHg). Median change for SBP was –1.20 mmHg (range –2.10 to +0.21 mmHg).
People with hypertension:
One study investigated the effects of orlistat (120 mg three times a day) over 12 months in people with hypertension.
There was significantly greater weight loss in people taking orlistat compared with placebo (difference in weight loss = 2.7 kg, 95% CI 1.6 to 3.8). Mean absolute weight loss with orlistat was 5.4 kg.
There was a significantly greater decrease in TC in people taking orlistat compared with those taking placebo (0.32 mmol/L, 95% CI 0.17 to 0.47). Mean absolute change in TC with orlistat was –0.36 mmol/L.
There was a significantly greater decrease in DBP in people taking orlistat compared with those taking placebo (difference in DBP = 2.20 mmHg, 95% CI 0.78 to 3.62). The change in SBP did not reach significance (–2.30 mmHg, 95% CI –4.87 to +0.27). Mean absolute change for DBP was –11.4 mmHg. Mean absolute change for SBP was –13.30 mmHg.
A recent Health Technology Assessment conducted a systematic review (search date to January 2009) of the clinical effectiveness and cost-effectiveness of anti-obesity drugs in adults [Ara et al, 2012]. The review included orlistat, sibutramine, and rimonabant; sibutramine and rimonabant have since been withdrawn.
Clinical effectiveness
Studies were included if they compared drug treatment with standard care (lifestyle advice), placebo, or metformin. Only studies longer than 12 weeks were included. The analysis included 94 randomized controlled trials that met the inclusion criteria, the quality of the trials was reported to be generally low.
Overall, drug treatment was effective at reducing weight and body mass index (BMI) compared with placebo.
Cost-effectiveness
Sixteen economic evaluations were identified that reviewed the costs and benefits associated with the three drug treatments.
Compared with lifestyle advice, the mean incremental cost-effectiveness ratio for orlistat ranged between £970 to £59,174.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of obesity.
Search dates
2007 - August 2012
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Obesity/, obese.tw., obesity.tw., overweight.tw., (over ADJ weight).tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
Institute for Clinical Systems Improvement
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
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