Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Obesity - Management
View full scenario

How should I manage someone with a BMI 35-39.9 (obesity II)

  • No comorbidities present: offer structured advice regarding diet and physical activity. Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
  • Comorbidities present (such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, and sleep apnoea):
    • Offer structured advice regarding diet and physical activity.
    • Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
    • Consider referral for surgery (according to local policies and protocol).

In depth

What advice should I give about diet?

  • Take into account the person's food preferences and allow for flexible approaches to reducing calorie intake.
  • 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.
  • Do not use unduly restrictive and nutritionally unbalanced diets.

In depth

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 (e.g. 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, e.g. brisk walking, gardening, or cycling.
    • Supervised exercise programmes.
    • Other activities (e.g. swimming or stair climbing).

In depth

When should I consider prescribing drug treatment?

  • Only consider drug treatment after dietary, physical activity, and behavioural approaches have been started and evaluated.
  • Consider starting drug treatment in people with a BMI >= 35 kg/m2, or a BMI 27–35 kg/m2 if comorbidities are present.
  • Provide drug treatment as part of an integrated approach to weight management.

In depth

Which anti-obesity drug should I prescribe?

  • Orlistat is the anti-obesity drugs of choice when drug treatment is considered to be appropriate in primary care. For further information see Scenario: Prescribing orlistat.
  • Sibutramine is no longer prescribable in the UK — its marketing authorization has been suspended by the European Medicines Agency.

In depth

Prescriptions

Non-drug management

Age from 18 years onwards
Weight management advice
Age: from 18 years onwards
Licensed use: no
Patient information: Losing weight - The first steps: Follow this plan to lose weight over the next 3 months. 1. Aim for 5-10 kg weight loss over the 3 months, or 0.5 kg per week. But be realistic, if this seems too difficult, aim for a smaller weight loss, as even small amounts of weight loss bring health benefits. 2. A healthy balanced diet should be followed e.g. 1200-1600 kcal per day, moderate fat intake, more fruit and vegetables. 3. Increase the amount of daily routine activities you do e.g. walking, housework activities and stair climbing. Decrease the amount of time you spend sitting down. Build up an exercise programme that you enjoy e.g. swimming, walking, aerobics, cycling. 4. Contact a local slimming club if you think it will suit you. 5. If you smoke, quitting will bring great health benefits. 6. If you have hypertension, hyperlipidaemia or diabetes, the doctor can discuss it with you. 7. Make sure you tell others about your plans to lose weight, as the support of others can help you to stay motivated. Check in with your practice nurse, slimming club, weight management clinic or other support group regularly
Diet advice
Age: from 18 years onwards
Licensed use: no
Patient information: Dietary tips for weight loss: 1. Try to eat regular meals and serve smaller portions. 2. Reduce the amount of fat in your diet (bake, boil or grill food rather than frying it; use lower fat milk, dairy products and spreads and trim fat from meat and poultry; choose healthy snacks such as fruits as alternatives to sweets, chocolates, crisps, pies, cakes and biscuits). 3. Take low-calorie drinks instead of high sugar drinks, and reduce your alcohol intake. 4. Consider using a food diary to help establish and maintain these changes.
Physical activity advice
Age: from 18 years onwards
Licensed use: no
Patient information: Tips on physical activity for achieving weight loss: 1. Increase the amount of daily routine activity, such as shopping, walking, housework and gardening. 2. Decrease the amount of time you are inactive, for example, do not sit down for more than 30 minutes at a time. 3. Build up slowly towards 30 minutes-per-day of moderate intensity exercise (moderate intensity means breathing slightly more than normal, but still being comfortable enough to talk at the same time). Consider extending some exercise sessions to 45 minutes, to encourage the use of body fat. 4. The most effective activities for achieving weight loss are 'aerobic' activities that involve large muscle groups such as the buttocks and leg muscles. Activities include walking, swimming and cycling. 5. Consider weight-bearing exercises (where your body weight is lifted or moved along) such as walking or climbing stairs, as these help to conserve muscle mass and maintain strength and resting metabolic rate. 6. Choose physical activities that you enjoy, as this will help you stick to them.

Orlistat

Age from 18 to 75 years
Orlistat capsules: 120mg three times a day
Orlistat 120mg capsules
Take one capsule with each main meal. Maximum of 3 capsules in 24 hours. (Take each capsule just before, during, or up to 1 hour after a main meal.)
Supply 84 capsules.
Age: from 18 years to 75 years
NHS cost: £33.58
Licensed use: yes
Patient information: It is important that you still keep to your diet, and try to keep exercising, even though you have been prescribed orlistat. Make sure that you eat plenty of fruit and vegetables as part of your diet. Do not take a capsule if you miss a main meal, or the meal does not contain fat. Orlistat may cause urgent or increased need to open the bowels, flatulence with discharge, oily discharge, and oily or fatty stools. Limiting the fat in your diet will reduce these side effects. If you are taking multivitamins, do not take them during the 2 hours before, or the 2 hours after taking orlistat.

© NHS Institute for Innovation and Improvement