The video version of this podcast can be found here:

·      https://youtu.be/tgzpDd-LUR8

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in January 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for January 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-01-01&to=2025-01-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered in this episode can be found here:

The NICE guideline on Overweight and obesity management [NG246] can be found here:

·      https://www.nice.org.uk/guidance/ng246

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in January 2025, focusing on what is relevant in Primary Care only.

In today’s episode, there is only one area relevant to us, which is a brand-new guideline on overweight and obesity management, or NG246. This guideline consolidates and updates previous NICE recommendations on this topic. Today I will cover general principles of care, including BMI and waist-to-height ratio and pharmacological treatments.

Right, let’s jump into it.

As general principles of care, NICE emphasises a person-centred approach, advocating for non-judgmental communication and tailoring advice to individual circumstances, such as age, gender, cultural background, and socioeconomic status.

In terms of prevention, we should provide information and practical advice on diet and exercise, particularly focusing on people at high risk because of family history or co-morbidities. We will encourage self-monitoring of weight and waist measurements but also being conscious of the risks for those who have or might develop an eating disorder.

When advising about lifestyle, we will advise to avoid extreme physical activity or dietary behaviours that are difficult to sustain long term. 

We should explain that even small, gradual improvements to physical activity and dietary intake are likely to be helpful.

For discussions about children, we need to think about the impact of measuring their weight as well as their vulnerability to eating disorders, and for many children we should focus on weight maintenance and growing into a healthier weight, rather than weight loss. Additionally, for them we should use age- and sex-specific growth charts, to visually show their weight and BMI centile. 

Furthermore, for children and young people, the main responsibility for behavioural changes should fall upon their families and carers, taking into account the maturity of the child and their preferences. We should also encourage them to get enough sleep, explaining that lack of sleep may increase the risk of excess weight gain.

In primary care, we should routinely assess BMI but also waist circumference to assess central adiposity, which is linked to increased morbidity.

We can classify the degree of overweight or obesity in adults using BMI or waist-to-height ratio.

In terms of BMI:

• overweight: is a BMI of 25 to 29.9 kg/m2
• obesity class 1: is a BMI of 30 to 34.9 kg/m2
• obesity class 2: is a BMI of 35 to 39.9 kg/m2
• and obesity class 3: is a BMI of 40 kg/m2 or more.
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People with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African–Caribbean background are prone to central adiposity and their cardiometabolic risk occurs at lower BMIs, so all these thresholds should be lower BMI. And so:

• overweight for them would be a BMI of 23 kg/m2 to 27.4 kg/m2
• and obesity would be a BMI of 27.5 kg/m2 or above. For obesity classes 2 and 3 we will also reduce the thresholds by 2.5 kg/m2. 

BMI is not a perfect measurement so we will interpret BMI with caution in people aged 65 and over and those with high muscle mass.

In children, we will use BMI centiles and standard variations. I will not go through the thresholds in detail today but I will just mention that anything higher than the 91st centile is high.

We should also encourage the calculation of waist-to-height ratio. For this, they should measure their waist circumference and height in the same units and divide the waist measurement by the height measurement.

The waist-to-height ratio thresholds can be:

• healthy when the ratio is between 0.4 to 0.49.
• increased when the ratio is between 0.5 to 0.59 and
• high when the ratio is 0.6 or more, indicating further increased health risks.
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Therefore, when talking to a person about their waist-to-height ratio, we should explain that they should try and keep their waist to less than half their height that is, under 0.5.

The waist-to-height ratio classification can be used for adults and children of both sexes and all ethnicities, including those with high muscle mass.

The health risks associated with higher levels of central adiposity include type 2 diabetes, hypertension and cardiovascular disease. 

And now let’s have a look at the drug treatment.

NICE has provided detailed guidance on medicines for weight management in adults and children.

Here are the main key facts:

1. Medicines approved include Orlistat, Tirzepatide, Semaglutide, and Liraglutide.
2. For overweight and obesity, semaglutide, and liraglutide should be prescribed by secondary care only.
3. Orlistat is taken as an oral capsule up to three times a day and it can be prescribed in Primary Care for those with a BMI of 30 kg/m2 or more or a BMI of 28 kg/m2 or more and associated risk factors. It should be stopped after 12 weeks if at least 5% of the initial body weight has not been lost.
4. Tirzepatide is given as weekly subcutaneous injections and it is also approved to use in Primary Care for those with a BMI of at least 35 kg/m² with at least one weight-related comorbidity. For people with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African–Caribbean background, the BMI threshold is reduced by 2.5 kg/m² to 32.5. However, tirzepatide is subject to a gradual NHS rollout process, so there may be local variations in its availability on the NHS. If less than 5% of the initial weight has been lost after 6 months on the highest tolerated dose, we will need to decide whether to continue treatment, taking into account its benefits and risks.
5. These drugs are not recommended during pregnancy and generally not recommended for those under 12. For children 12 and above, specialist services must be involved.

Bariatric surgery is an option for people with severe obesity. NICE recommends referral for adults if:

1. The BMI is 40 kg/m² or more or
2. The BMI is between 35 and 39.9 kg/m² with significant health conditions that could improve with weight loss, such as type 2 diabetes or obstructive sleep apnoea.
3. For expedited assessments, people with a BMI of 35 or more and recent-onset (that is, diagnosed within the past 10 years) type 2 diabetes and
4. We will bear in mind that ethnic-specific adjustments will lower BMI thresholds by 2.5 kg/m² for groups at higher risk of cardiometabolic complications.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.