Nice | Obesity; consider early referral

This updated guideline from NICE looks at obesity. The big changes from the 2006 guideline have been well publicised in the news and mainly advise that referral for bariatric surgery be considered at a lower BMI to previously, especially where the patient has new onset Type 2 Diabetes Mellitus (T2DM).

Most of the rest of the guideline isn't significantly different, but I am summarising the main points below.

How to assess someone who is overweight

Children - use age / sex adjusted charts to work out the significance of their BMI. Charts can be accessed here.

Adults - calculate their BMI and their waist circumference. Use these to work out what intervention may be appropriate as follows:


  • Overweight 25 - 29.9
  • Obesity I 30 - 34.9
  • Obesity II 35 - 39.9
  • Obesity III 40 or more

Waist circumference in obesity

  • Low - < 94 cm in men / 80cm for women
  • High - 94 - 102 cm in men / 80 - 88 cm for women
  • Very High -  > 102 cm in men / 88cm for women

Obesity interventions advised

  1. General advice on healthy weight and lifestyle
  2. Diet and physical activity
  3. Diet and physical activity and consider drugs
  4. Diet and physical activity, consider drugs and consider surgery

In children, consider targeted advice if their BMI lies on or above the 91st percentile (as per the above charts).

Diet Advice

Most of this is as you would expect. They don't advice very low calorie diets be used routinely, but they can be considered where rapid weight loss is needed (eg before joint surgery or fertility treatment).

Where a very low calorie diet is going to be used (ie under 800 calories), you must ensure that it is nutritionally complete, that it isn't used for more than 12 weeks, that patients have ongoing clinical support and that they understand that they may put weight on again afterwards.

Physical Activity

This has not changed - but a quick reminder:

  •  Most people - 30 mins 5 times a week
  • To avoid weight gain - 45 to 60 mins a week
  • If a patient has been obese and lost weight and wishes to avoid regaining it - 60 to 90 min
  • Children - 60 mins a day and ensure that inactivity is reduced

Drug Treatment

  • Use only after dietary, physical activity and behavioural approaches have been tried and evaluated.
  • Regular review is required.
  • Orlistat can be used to help maintain weight loss.
  • It should be continued after 3 months, only if the patient has lost 5% or more of their weight.
  • BMI to use it at
    • 28 - with co-morbidities
    • 30 or more - without co-morbidities.

Surgery for obesity

Can be considered under the following circumstances:

  • Has been receiving treatment in a Tier 3 service
  • Commits to ongoing follow-up (normally 2 yrs under the specialist then annually to 'ensure nutritional status')
  • Diet, physical activity and behavioural interventions have been tried and the patient has failed to lose weight or to maintain the weight loss
  • BMI
    • 40 or more without co-morbidities
    • 35 to 40 with co-morbidities (eg Type 2 Diabetes or hypertension)
  • Recent onset Type 2 Diabetes AND BMI 35 or more (alongside Tier 3 services)
  • BMI 30 to 34.9 then consider referral (alongside Tier 3 services)
  • Asian Origin - consider at a lower BMI

Referrals to Tier 3 Services

Consider if

  • Underlying cause of weight problems needs addressing
  • Complex disease states or underlying medical problems (eg learning difficulties)
  • Conventional treatment is unsuccessful
  • Drug treatment is being considered and their BMI is more than 50
  • Specialist interventions may be needed (eg very low calorie diet)
  • Surgery is being considered

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