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Guideline Summary
Guideline Title
Management of obesity. A national clinical guideline.
Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Feb. 96 p. (SIGN publication; no. 115).  [319 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity in children and young people. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Apr. 24 p. (SIGN publication; no. 69). [117 references]

Any amendments to the guideline in the interim period will be noted on the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.

Scope

Disease/Condition(s)

Obesity

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Endocrinology
Family Practice
Internal Medicine
Nursing
Nutrition
Pediatrics
Preventive Medicine
Psychology
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To provide evidence-based recommendations on the prevention and treatment of obesity in children, young people and adults within the clinical setting

Target Population

Children, young people, and adults with overweight and obesity

Interventions and Practices Considered

Adults

  1. Diagnosis
    • Body mass index (BMI)
    • Waist circumference to refine assessment of risk of obesity-related comorbidities
  2. Prevention
    • Provision of information regarding dietary factors, physical activity, and self-weighing
  3. Identification and intervention for high-risk adults
  4. Education on health benefits associated with sustained modest weight loss
  5. Assessment of patient willingness to change
  6. Weight management programs
    • Physical activity
    • Dietary interventions
    • Individual or group based psychological/behavioural interventions
  7. Internet-based weight management programs
  8. Pharmacologic therapy with Orlistat
  9. Bariatric surgery

Children and Young People

  1. Diagnosis
    • BMI centile
    • Waist circumference (discussed but not recommended)
    • International obesity task force cut-offs (discussed but not recommended)
  2. Prevention through school-based interventions
  3. Family-based treatment programs
    • Reduction of dietary energy intake
    • Increased physical activity levels
    • Minimisation of sedentary behaviours
  4. Establishment of treatment goals
  5. Referral to hospital or specialist paediatric services
  6. Pharmacologic therapy with Orlistat
  7. Bariatric surgery
Major Outcomes Considered

Adults

  • Percentage of adults with intentional weight loss
  • Percentage of adults who maintain weight loss
  • Duration of weight loss maintenance
  • Changes in morbidity and mortality associated with obesity
  • Morbidity and mortality associated with weight loss regimens/procedures

Children and Young People

  • Change in body mass index (BMI) centile
  • Percentage of children and adolescents who maintain weight loss
  • Duration of weight loss maintenance
  • Morbidity and mortality associated with obesity
  • Morbidity and mortality associated with weight loss regimens/procedures

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Systematic Literature Review

The evidence base for this guideline was synthesised in accordance with Scottish Intercollegiate Guidelines Network (SIGN) methodology. A systematic review of the literature was carried out using a search strategy devised by a SIGN Information Officer. Databases searched included Medline, Embase, Cinahl, PsycINFO and The Cochrane Library. The date range varied for each of the searches, and depended largely on how much literature was available. Internet searches were carried out on various websites including the New Zealand Guidelines Programme, NELH Guidelines Finder, and the U.S. National Guideline Clearinghouse. The Medline version of the main search strategies can be found on the SIGN website, in the section covering supplementary guideline material. The date ranges for each of the searches are also detailed in this section. The main searches were supplemented by material identified by individual members of the development group.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+ - Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1- - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 - Non-analytic studies, e.g., case reports, case series

4 - Expert opinion

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Once papers have been selected as potential sources of evidence, the methodology used in each study is assessed to ensure its validity. The result of this assessment will affect the level of evidence allocated to the paper, which will in turn influence the grade of recommendation that it supports.

The methodological assessment is based on a number of key questions that focus on those aspects of the study design that research has shown to have a significant influence on the validity of the results reported and conclusions drawn. These key questions differ between study types, and a range of checklists is used to bring a degree of consistency to the assessment process. The Scottish Intercollegiate Guidelines Network (SIGN) has based its assessments on the MERGE (Method for Evaluating Research and Guideline Evidence) checklists developed by the New South Wales Department of Health, which have been subjected to wide consultation and evaluation. These checklists were subjected to detailed evaluation and adaptation to meet SIGN's requirements for a balance between methodological rigour and practicality of use.

The assessment process inevitably involves a degree of subjective judgement. The extent to which a study meets a particular criterion—e.g., an acceptable level of loss to follow up—and, more importantly, the likely impact of this on the reported results from the study will depend on the clinical context. To minimise any potential bias resulting from this, each study must be evaluated independently by at least two group members. Any differences in assessment should then be discussed by the full group. Where differences cannot be resolved, an independent reviewer or an experienced member of SIGN executive staff will arbitrate to reach an agreed quality assessment.

Evidence Tables

Evidence tables are compiled by SIGN executive staff based on the quality assessments of individual studies provided by guideline development group members. The tables summarise all the validated studies identified from the systematic literature review relating to each key question. They are presented in a standard format to make it easier to compare results across studies, and will present separately the evidence for each outcome measure used in the published studies. These evidence tables form an essential part of the guideline development record and ensure that the basis of the guideline development group's recommendations is transparent.

Additional details can be found in the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50]), available from the SIGN Web site External Web Site Policy.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The National Institute for Health and Clinical Excellence (NICE) published a comprehensive obesity guideline for England and Wales in December 2006. To avoid duplication of effort SIGN utilised and updated evidence tables produced by NICE, where appropriate, as a basis for considered judgement. The ADAPTE process for guideline adaptation was followed.

Synthesising the Evidence

Guideline recommendations are graded to differentiate between those based on strong evidence and those based on weak evidence. This judgement is made on the basis of an (objective) assessment of the design and quality of each study and a (perhaps more subjective) judgement on the consistency, clinical relevance and external validity of the whole body of evidence. The aim is to produce a recommendation that is evidence based, but which is relevant to the way in which health care is delivered in Scotland and is therefore implementable.

It is important to emphasise that the grading does not relate to the importance of the recommendation, but to the strength of the supporting evidence and, in particular, to the predictive power of the study designs from which that data was obtained. Thus, the grading assigned to a recommendation indicates to users the likelihood that, if that recommendation is implemented, the predicted outcome will be achieved.

Considered Judgement

It is rare for the evidence to show clearly and unambiguously what course of action should be recommended for any given question. Consequently, it is not always clear to those who were not involved in the decision making process how guideline developers were able to arrive at their recommendations, given the evidence they had to base them on. In order to address this problem, the Scottish Intercollegiate Guidelines Network (SIGN) has introduced the concept of considered judgement.

Under the heading of considered judgement, guideline development groups summarise their view of the total body of evidence covered by each evidence table. This summary view is expected to cover the following aspects:

  • Quantity, quality, and consistency of evidence
  • External validity (generalisability) of study findings
  • Directness of application to the target population for the guideline
  • Any evidence of potential harms associated with implementation of a recommendation
  • Clinical impact (i.e., the extent of the impact on the target patient population, and the resources needed to treat them in accordance with the recommendation)
  • Whether, and to what extent, any equality groups may be particularly advantaged or disadvantaged by the recommendations made
  • Implementability (i.e., how practical it would be for the National Health Service [NHS] in Scotland to implement the recommendation)

The group is finally asked to summarise its view on all of these issues, both the quality of the evidence and its potential impact, before making a graded recommendation. This summary should be succinct, and taken together with its views of the level of evidence represent the first draft of the text that will appear in the guideline immediately before a graded recommendation.

Additional detail about SIGN's process for formulating guideline recommendations is provided in Section 6 of the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50]), available from the SIGN Web site External Web Site Policy.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: recommended best practice based on the clinical experience of the guideline development group

Cost Analysis

A National Cost and Resource Impact Assessment based on the recommendations identified by the guideline development group as likely to have major resource implications for National Health Service Scotland (NHSScotland) is currently under development by NHS Quality Improvement Scotland (QIS). The report will be made available towards the end of 2010 and is being undertaken in partnership with the Scottish Health Technologies Group (www.nhshealthquality.org External Web Site Policy) and the newly established National Planning Forum. The assessment will summarise the likely resources required and the associated costs specifically with regard to weight management services and bariatric surgery with the objective of facilitating more rapid implementation.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The national open meeting is the main consultative phase of Scottish Intercollegiate Guidelines Network (SIGN) guideline development, at which the guideline development group presents its draft recommendations for the first time. The national open meeting for this guideline was held on 27th October 2008. Two hundred and twenty eight people participated. The draft guideline was also available on the SIGN Web site External Web Site Policy for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline.

Peer Review

All SIGN guidelines are reviewed in draft form by independent expert referees, who are asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline. A number of general practitioners (GPs) and other primary care practitioners also provide comments on the guideline from the primary care perspective, concentrating particularly on the clarity of the recommendations and their assessment of the usefulness of the guideline as a working tool for the primary care team. The draft is also sent to at least two lay reviewers in order to obtain comments from the patient's perspective.

It should be noted that all reviewers are invited to comment as individuals, not as representatives of any particular organisation or group. Corporate interests, whether commercial, professional, or societal have an opportunity to make representations at the national meeting stage where they can send representatives to the meeting or provide comment on the draft produced for that meeting. Peer reviewers are asked to complete a declaration of interests form.

The comments received from peer reviewers and others are carefully tabulated and discussed with the Chair and with the guideline development group. Each point must be addressed and any changes to the guideline as a result noted or, if no change is made, the reasons for this recorded.

As a final quality control check prior to publication, the guideline and the summary of peer reviewers' comments are reviewed by the SIGN Editorial Group for that guideline to ensure that each point has been addressed adequately and that any risk of bias in the guideline development process as a whole has been minimised. Each member of the guideline development group is then asked formally to approve the final guideline for publication.

Recommendations

Major Recommendations

Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.

The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Key Recommendations

The following recommendations were highlighted by the guideline development group as being clinically very important. They are the key clinical recommendations that should be prioritised for implementation. The clinical importance of these recommendations is not dependent on the strength of the supporting evidence.

Prevention of Overweight and Obesity in Adults

B - Individuals consulting about weight management should be advised to reduce:

  • Intake of energy-dense foods (including foods containing animal fats, other high fat foods, confectionery and sugary drinks) by selecting low energy-dense foods instead (for example whole grains, cereals, fruits, vegetables and salads)
  • Consumption of 'fast foods' (e.g., 'take-aways')
  • Alcohol intake

B - Individuals consulting about weight management should be encouraged to be physically active and reduce sedentary behaviour, including television watching.

Assessment in Adults

D - Healthcare professionals should discuss willingness to change with patients and then target weight loss interventions according to patient willingness around each component of behaviour required for weight loss, e.g., specific dietary and/or activity changes.

Weight Management Programmes and Support for Weight Loss Maintenance in Adults

A - Weight management programmes should include physical activity, dietary change and behavioural components.

Dietary Interventions in Adults

A - Dietary interventions for weight loss should be calculated to produce a 600 kcal/day energy deficit. Programmes should be tailored to the dietary preferences of the individual patient.

Physical Activity in Adults

B - Overweight and obese individuals should be prescribed a volume of physical activity equal to approximately 1,800 to 2,500 kcal/week. This corresponds to approximately 225 to 300 min/week of moderate intensity physical activity (which may be achieved through five sessions of 45 to 60 minutes per week, or lesser amounts of vigorous physical activity).

Pharmacological Treatment in Adults

A - Orlistat should be considered as an adjunct to lifestyle interventions in the management of weight loss. Patients with BMI ≥28 kg/m2 (with comorbidities) or BMI ≥30 kg/m2 should be considered on an individual case basis following assessment of risk and benefit.

Bariatric Surgery in Adults

C - Bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in patients who fulfil the following criteria:

  • BMI ≥35 kg/m2
  • Presence of one or more severe comorbidities which are expected to improve significantly with weight reduction (e.g., severe mobility problems, arthritis, type 2 diabetes).

Diagnosis and Screening in Children and Young People

C - BMI centiles should be used to diagnose overweight and obesity in children.

Prevention of Overweight and Obesity in Children and Young People

C - Sustainable school-based interventions to prevent overweight and obesity should be considered by and across agencies. Parental/family involvement should be actively facilitated.

Treatment of Obesity in Children and Young People

B - Treatment programmes for managing childhood obesity should incorporate behaviour change components, be family based, involving at least one parent/carer and aim to change the whole family's lifestyle. Programmes should target decreasing overall dietary energy intake, increasing levels of physical activity and decreasing time spent in sedentary behaviours (screen time).

D - In most obese children (BMI ≥98th centile) weight maintenance is an acceptable treatment goal.

D - Weight maintenance and/or weight loss can only be achieved by sustained behavioural changes, e.g.,:

  • Healthier eating, and decreasing total energy intake
  • Increasing habitual physical activity (e.g., brisk walking). In healthy children, 60 minutes of moderate-vigorous physical activity/day is recommended
  • Reducing time spent in sedentary behaviour (e.g., watching television and playing computer games) to <2 hours/day on average or the equivalent of 14 hours/week.

D - The following groups should be referred to hospital or specialist paediatric services before treatment is considered:

  • Children who may have serious obesity-related morbidity that requires weight loss (e.g., benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, orthopaedic problems and psychological morbidity)
  • Children with a suspected underlying medical (e.g., endocrine) cause of obesity including all children under 24 months of age who are severely obese (BMI ≥99.6th centile).

D - Orlistat should only be prescribed for severely obese adolescents (those with a BMI ≥99.6th centile of the United Kingdom (UK) 1990 reference chart for age and sex) with comorbidities or those with very severe to extreme obesity (BMI ≥3.5 standard deviations (SD) above the mean of the UK 1990 reference chart for age and sex) attending a specialist clinic. There should be regular reviews throughout the period of use, including careful monitoring for side effects.

D - Bariatric surgery can be considered for postpubertal adolescents with very severe to extreme obesity (BMI ≥3.5 SD above the mean on 1990 UK charts) and severe comorbidities.

Diagnosing Overweight and Obesity in Adults

Body Mass Index

B - BMI should be used to classify overweight or obesity in adults.

Waist Circumference

C - Waist circumference may be used, in addition to BMI, to refine assessment of risk of obesity-related comorbidities.

Prevention of Overweight and Obesity in Adults

Dietary Factors

B - Individuals consulting about weight management should be advised to reduce:

  • Intake of energy-dense foods (including foods containing animal fats, other high fat foods, confectionery and sugary drinks) by selecting low energy-dense foods instead (for example whole grains, cereals, fruits, vegetables and salads)
  • Consumption of 'fast foods' (e.g., 'take-aways')
  • Alcohol intake

Physical Activity

B - Individuals consulting about weight management should be encouraged to be physically active and reduce sedentary behaviour, including television watching.

Self-weighing

B - Adults consulting about weight management should be encouraged to undertake regular self-weighing.

Identifying High Risk Groups in Adults

Factors Associated with Risk of Overweight and Obesity

Smoking Cessation

B - Healthcare professionals should offer weight management interventions to patients who are planning to stop smoking.

Medication

B - Weight management measures should be discussed with patients who are prescribed medications associated with weight gain.

B - Where relevant, patients should be advised that use of combined contraceptives or hormone replacement therapy is not associated with significant weight gain.

Health Benefits of Weight Loss in Adults

Healthcare professionals should make patients aware of the following health benefits associated with sustained modest weight loss:

  • Improved lipid profiles - A
  • Reduced osteoarthritis-related disability - A
  • Lowered all-cause, cancer and diabetes mortality in some patient groups - B
  • Reduced blood pressure - B
  • Improved glycaemic control - B
  • Reduction in risk of type 2 diabetes - B
  • Potential for improved lung function in patients with asthma - B

Assessment in Adults

Assessing Motivation for Behaviour Change

D - Healthcare professionals should discuss willingness to change with patients and then target weight loss interventions according to patient willingness around each component of behaviour required for weight loss, e.g., specific dietary and/or activity changes.

Binge-eating Disorder

C - Healthcare professionals should be aware of the possibility of binge-eating disorder in patients who have difficulty losing weight and maintaining weight loss.

Weight Management Programmes and Support for Weight Loss Maintenance in Adults

Diet Plus Physical Activity Plus Behavioural Therapy

A - Weight management programmes should include physical activity, dietary change and behavioural components.

Internet-based Weight Management Programs

B - Delivery of evidence-based weight management programmes through the internet should be considered as part of a range of options for patients with obesity.

Dietary Interventions in Adults

A - Dietary interventions for weight loss should be calculated to produce a 600 kcal/day energy deficit. Programmes should be tailored to the dietary preferences of the individual patient.

D - Where very low calorie diets are indicated for rapid weight loss, these should be conducted under medical supervision.

Physical Activity in Adults

Physical Activity Dose

A - Overweight or obese individuals should be supported to undertake increased physical activity as part of a multicomponent weight management programme.

B - Overweight and obese individuals should be prescribed a volume of physical activity equal to approximately 1,800 to 2,500 kcal/week. This corresponds to approximately 225 to 300 min/week of moderate intensity physical activity (which may be achieved through five sessions of 45 to 60 minutes per week, or lesser amounts of vigorous physical activity).

Psychological/Behavioural Interventions in Adults

A - Individual or group-based psychological interventions should be included in weight management programmes.

Pharmacological Treatment in Adults

Orlistat

A - Orlistat should be considered as an adjunct to lifestyle interventions in the management of weight loss. Patients with BMI ≥28 kg/m2 (with comorbidities) or BMI ≥30 kg/m2 should be considered on an individual case basis following assessment of risk and benefit.

Bariatric Surgery in Adults

C - Bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in patients who fulfil the following criteria:

  • BMI ≥35 kg/m2
  • Presence of one or more severe comorbidities which are expected to improve significantly with weight reduction (e.g., severe mobility problems, arthritis, type 2 diabetes)

C - Binge-eating disorder, dysfunctional eating behaviour, past history of intervention for substance misuse, psychological dysfunction or depression should not be considered absolute contraindications for surgery.

Diagnosis and Screening in Children and Young People

Diagnosis of Overweight and Obesity in Children and Young People

BMI, Waist Circumference and International Cut-offs

C - BMI centiles should be used to diagnose overweight and obesity in children.

C - Waist circumference should not be used to diagnose overweight and obesity in children.

D - International obesity task force cut-offs should not be used to diagnose overweight and obesity in children.

Epidemiological and Clinical Use of BMI Centile

D - For clinical use, obese children are those with a BMI ≥98th centile of the UK 1990 reference chart for age and sex.

Prevention of Overweight and Obesity in Children and Young People

C - Sustainable school-based interventions to prevent overweight and obesity should be considered by and across agencies. Parental/family involvement should be actively facilitated.

Treatment of Obesity in Children and Young People

Lifestyle Interventions

B - Treatment programmes for managing childhood obesity should incorporate behaviour change components, be family based, involving at least one parent/carer and aim to change the whole family's lifestyle. Programmes should target decreasing overall dietary energy intake, increasing levels of physical activity and decreasing time spent in sedentary behaviours (screen time).

Planning Treatment

Treatment Goals in Children and Young People

D - In most obese children (BMI ≥98th centile) weight maintenance is an acceptable treatment goal.

D - For children with a BMI ≥99.6th centile a gradual weight loss to a maximum of 0.5 to 1.0 kg per month is acceptable.

D - Weight maintenance and/or weight loss can only be achieved by sustained behavioural changes, e.g.,:

  • Healthier eating, and decreasing total energy intake
  • Increasing habitual physical activity (e.g., brisk walking). In healthy children, 60 minutes of moderate-vigorous physical activity/day is recommended
  • Reducing time spent in sedentary behaviour (e.g., watching television and playing computer games) to <2 hours/day on average or the equivalent of 14 hours/week.

D - In overweight children (91st to <98th BMI centile) weight maintenance is an acceptable goal. Annual monitoring of BMI centile may be appropriate to help reinforce weight maintenance and reduce the risk of overweight children becoming obese.

Referral

D - The following groups should be referred to hospital or specialist paediatric services before treatment is considered:

  • Children who may have serious obesity-related morbidity that requires weight loss (e.g., benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, orthopaedic problems and psychological morbidity)
  • Children with a suspected underlying medical (e.g., endocrine) cause of obesity including all children under 24 months of age who are severely obese (BMI ≥99.6th centile).

Pharmacological Treatment in Young People

D - Orlistat should only be prescribed for severely obese adolescents (those with a BMI ≥99.6th centile of the UK 1990 reference chart for age and sex) with comorbidities or those with very severe to extreme obesity (BMI ≥3.5 SD above the mean of the UK 1990 reference chart for age and sex) attending a specialist clinic. There should be regular reviews throughout the period of use, including careful monitoring for side effects.

Surgical Treatment in Young People

D - Bariatric surgery can be considered for postpubertal adolescents with very severe to extreme obesity (BMI ≥3.5 SD above the mean on 1990 UK charts) and severe comorbidities.

Definitions:

Level of Evidence

1++ - High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+ - Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1- - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ - High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ - Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 - Non-analytic studies, e.g., case reports, case series

4 - Expert opinion

Grade of Recommendations

A - At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or randomised controlled trial rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B - A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C - A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rate as 2++

D - Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Clinical Algorithm(s)

The original guideline document contains clinical algorithms for:

  • Suggested primary care pathway for adults with overweight and obesity
  • Suggested primary care pathway for children and young people with overweight and obesity

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate management and treatment of adults, children, and young people with overweight and obesity
  • Health benefits associated with sustained modest weight loss include:
    • Improved lipid profiles
    • Reduced osteoarthritis-related disability
    • Lowered all-cause, cancer and diabetes mortality in some patient groups
    • Reduced blood pressure
    • Improved glycaemic control
    • Reduced risk for type 2 diabetes
    • Potential for improved lung function in patients with asthma
Potential Harms

Pharmacotherapy

Orlistat treatment is associated with increased rates of gastrointestinal events. These are usually mild and transient.

Bariatric Surgery

  • Slightly increased mortality
  • Bleeding
  • Thromboembolic events
  • Wound complications
  • Deep infection—abscess or leak
  • Pulmonary complications
  • Miscellaneous complications
  • Need for re-operation

Male Patients

Male patients who receive bariatric surgery (adjustable or non-adjustable gastric banding, vertical banding gastroplasty or gastric bypass) have a 4.2 times increased incidence of cholelithiasis, 4.5 times increased incidence of cholecystitis and a 5.4 times increased incidence of cholecystectomy compared to patients receiving the best available non-surgical weight loss treatment.

Qualifying Statements

Qualifying Statements

This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is, however, advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

Prescribing of Medicines Outwith Their Marketing Authorisation

Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as "off label" use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons. Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience.

Medicines may be prescribed without their product licence in the following circumstances:

  • For an indication not specified within the marketing authorisation
  • For administration via a different route
  • For administration of a different dose

"Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers' professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines."*

*The British National Formulary No 58. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2009.

Any practitioner following a Scottish Intercollegiate Guidelines Network (SIGN) recommendation and prescribing a licenced medicine outwith the product licence needs to be aware that they are responsible for this decision, and in the event of adverse outcomes, may be required to justify the actions that they have taken.

Prior to prescribing, the licensing status of a medication should be checked in the current version of the British National Formulary (BNF).

In the event of errors or omissions corrections will be published in the web version of the guideline, which is the definitive version at all times. This version can be found on the web site www.sign.ac.uk External Web Site Policy.

Implementation of the Guideline

Description of Implementation Strategy

Implementing the Guideline

Implementation of national clinical guidelines is the responsibility of each National Health Service (NHS) Board and is an essential part of clinical governance. Mechanisms should be in place to review care provided against the guideline recommendations. The reasons for any differences should be assessed and addressed where appropriate. Local arrangements should then be made to implement the national guideline in individual hospitals, units and practices.

Resource Implications of Key Recommendations

A National Cost and Resource Impact Assessment based on the recommendations identified by the guideline development group as likely to have major resource implications for NHSScotland is currently under development by NHS Quality Improvement Scotland (QIS). The report will be made available towards the end of 2010 and is being undertaken in partnership with the Scottish Health Technologies Group (www.nhshealthquality.org External Web Site Policy) and the newly established National Planning Forum. The assessment will summarise the likely resources required and the associated costs specifically with regard to weight management services and bariatric surgery with the objective of facilitating more rapid implementation.

Auditing Current Practice

A first step in implementing a clinical practice guideline is to gain an understanding of current clinical practice. Audit tools designed around guideline recommendations can assist in this process. Audit tools should be comprehensive but not time consuming to use. Successful implementation and audit of guideline recommendations requires good communication between staff and multidisciplinary team working.

The guideline development group has identified the following as key points to audit to assist with the implementation of this guideline:

  • Percentage of identified adult patients with a body mass index (BMI) >30 kg/m2 who have access to/are participating in a weight management programme which includes physical activity, dietary change and behavioural components
  • Percentage of adult patients appropriately prescribed pharmacological treatment as an adjunct to lifestyle interventions
  • Percentage of severely obese adult patients, BMI ≥35 kg/m2, undergoing surgery as a treatment option for obesity, where locally derived criteria have been observed
  • Percentage of identified obese children with serious obesity-related morbidity or suspected underlying cause who have been referred to hospital or specialist paediatric services
  • Percentage of identified overweight or obese children who are offered a multicomponent family based weight management intervention.
Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Feb. 96 p. (SIGN publication; no. 115).  [319 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 Apr (updated 2010 Feb)
Guideline Developer(s)
Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]
Source(s) of Funding

Scottish Executive Health Department

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group: Ms Joyce Thompson (Co-Chair), Dietetic Consultant in Public Health Nutrition, National Health Service (NHS), Tayside; Dr David Wilson (Co-Chair), Reader in Paediatric Gastroenterology and Nutrition, University of Edinburgh; Dr Satinder Bal, Consultant in Endocrinology, Raigmore Hospital, Inverness; Dr Ewan Bell, Consultant Clinical Biochemist, Dumfries and Galloway Royal Infirmary; Dr Susan Boyle, Consultant Clinical Psychologist, Glasgow and Clyde Weight Management Service; Mr Duff Bruce, Consultant Surgeon, Aberdeen Royal Infirmary; Ms Fiona Clarke, Senior Health Promotion Specialist, NHS Highland, Inverness; Ms Kim Ferrier, Specialist Bariatric Physiotherapist, Glasgow and Clyde Weight Management Service; Ms Lorna Forde, Service Lead, Glasgow and Clyde Weight Management Service; Dr Jason Gill, Senior Lecturer in Exercise Science, Glasgow University; Dr Gail Haddock, General Practitioner, Cromarty; Dr Catherine Hankey, Senior Lecturer in Human Nutrition, Glasgow University; Dr Rosaleen Isles, Cognitive Therapist, Dumfries and Galloway Royal Infirmary; Ms Susan Kayes, Public Health Nurse, Cathkin High School, Glasgow; Ms Joanna Kelly, Information Officer, Scottish Intercollegiate Guidelines Network (SIGN); Dr Jennifer Logue, Clinical Lecturer in Metabolic Medicine, Glasgow University; Dr Kevin McConville, General Practitioner, Buckhaven; Ms Pamela McIntosh, Advanced Specialist Dietitian, NHS Forth Valley; Ms Aileen Muir, Consultant in Pharmaceutical Public Health, NHS Lothian; Professor John Reilly, Head of Childhood Obesity Group, Queen Mother's Hospital, Glasgow; Dr Finn Romanes (Chair, Prevention subgroup), Consultant in Public Health Medicine (Health Protection), NHS Tayside; Professor Naveed Sattar (Chair, Treatment subgroup), Professor of Metabolic Medicine, Glasgow University; Dr Laura Stewart, Team Lead, Paediatric Obesity Service, NHS Tayside; Ms Mae Stewart, Lay Representative, Dundee; Dr Lorna Thompson, Programme Manager, SIGN; Ms Elizabeth White, Health Visitor/Public Health Team Leader, Oban and Lorn Medical Centre, Oban

Financial Disclosures/Conflicts of Interest

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity in children and young people. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Apr. 24 p. (SIGN publication; no. 69). [117 references]

Any amendments to the guideline in the interim period will be noted on the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Quick reference guide: Management of obesity in children and young people. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Feb. Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.
  • Management of obesity in children and young people. Summary of recommendations. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2010 Feb. 4 p. Electronic copies: Available from the SIGN Web site External Web Site Policy.
  • SIGN 50: a guideline developer's handbook. Edinburgh (UK): Scottish Intercollegiate Guidelines Network. (SIGN publication; no. 50). Available in PDF from the SIGN Web site External Web Site Policy.
  • Appraising the quality of clinical guidelines. The SIGN guide to the AGREE (Appraisal of Guidelines Research and Evaluation) guideline appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2001. Available from the SIGN Web site External Web Site Policy.

Additionally, suggested key points to audit, as well as sample charts, assessment tools, and patient questionnaires are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on November 20, 2003. The information was verified by the guideline developer on January 16, 2004. This summary was completed by ECRI Institute on May 10, 2010.

Copyright Statement

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are subject to copyright; however, SIGN encourages the downloading and use of its guidelines for the purposes of implementation, education, and audit.

Users wishing to use, reproduce, or republish SIGN material for commercial purposes must seek prior approval for reproduction in any medium. To do this, please contact sara.twaddle@nhs.net.

Additional copyright information is available on the SIGN Web site External Web Site Policy.

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