• 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: Prescribing orlistat: covers prescribing issues and how to monitor a person taking orlistat.

• 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 classify 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, as it is a less accurate measure of adiposity in this group.

• Assess:
• Underlying causes and comorbidities.
• Risk of developing complications of obesity.
• Lifestyle in terms of diet and exercise.
• The potential health benefits of weight loss to the person.
• The person's feelings about being overweight.
• The person's willingness and motivation to try to lose weight.

In depth

• Take a history to include:
• Medical history — medical conditions that can contribute to overweight and obesity, or complications that may arise as a result of excess weight.
• Family history — overweight and obesity, and comorbidities.
• Drug history — medication that might cause weight gain.
• Social history — lifestyle, diet, exercise, alcohol and smoking, work and leisure activities.
• Check blood pressure using a large arm cuff.
• Check blood glucose and lipid profile, preferably on a fasting sample.
• Consider other tests if appropriate on the basis of assessment findings (e.g. liver function tests, thyroid function tests).

In depth

• 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.
• Using this information, assess whether the person is at increased risk of cardiovascular and metabolic complications. Note: Asian people may be at higher risk, and older people at lower risk, for a certain BMI compared with the general population.
• Ask about family history of diabetes (including gestational diabetes) and coronary heart disease.

In depth

• Determine if the person wants to lose weight at the present time by asking about concerns regarding weight, importance of losing weight, and quality of life issues.
• Explore barriers to lifestyle change (e.g. cost and availability of food, personal tastes, family views, disability or low levels of fitness, low self-esteem).

In depth

• If the underlying causes of overweight and obesity need to be assessed.
• If the person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care.
• If conventional treatment has failed in primary or secondary care.
• If specialist interventions (e.g. very-low-calorie diet for extended periods or surgery) may be needed.

In depth

• 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.
• 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.

In depth

• 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

• 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

• 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

• 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

• No comorbidities present: offer structured advice regarding diet and physical activity.
• 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.

In depth

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• Offer structured advice regarding diet and physical activity. This may be via a specialized weight management programme where available.
• Consider starting drug treatment once dietary and physical activity interventions have been evaluated.
• Consider referral for surgery (according to local criteria and policy).

In depth

• 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

• 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

• 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

• 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

• Orlistat is licensed for adults aged between 18 and 75 years who meet one of the following criteria:
• Body mass index (BMI) greater than or equal to 30 kg/m², or
• BMI greater than or equal to 28 kg/m² with comorbidities.

In depth

• Do not prescribe orlistat for someone with a chronic malabsorption syndrome or cholestasis.

In depth

• Fat-soluble vitamins or multivitamin supplements: if needed, they should be given at least 2 hours after a dose of orlistat or at bedtime.
• Ciclosporin: if concomitant use is unavoidable, monitor ciclosporin levels frequently, especially when starting or stopping orlistat.
• Warfarin: monitor international normalized ratio (INR) closely, especially when starting or stopping orlistat.
• Levothyroxine: consider giving at least 2 hours after a dose of orlistat or at bedtime.
• Antiepileptic drugs: consider giving at least 2 hours after a dose of orlistat or at bedtime.

In depth

• Orlistat is not recommended for use during pregnancy.
• Orlistat is contraindicated during breastfeeding.

In depth

• Gastrointestinal adverse effects are common (e.g. 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.

In depth

• Take orlistat immediately before, during, or up to 1 hour after each main meal (up to a maximum of three times a day).
• Omit the dose of orlistat if a meal is missed, or if the meal contains little or no fat.
• If a woman who is taking an oral contraceptive experiences severe diarrhoea whilst taking orlistat, advise her to use an additional method of contraception.

In depth

• Only continue orlistat beyond 3 months if the person has lost at least 5% of their body weight, as measured at the start of drug treatment.
• There is no restriction on how long orlistat may be prescribed. 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. Review at regular intervals.

In depth