Recommendations are marked as [new 2014], [2006], or [2006, amended 2014]:

• [new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated


• [2006] indicates that the evidence has not been reviewed since 2006


• [2006, amended 2014] indicates that the evidence has not been reviewed since 2006, but either:
  
  
  
  • Changes have been made to the recommendation wording that change the meaning, or
  
  
  • NICE has made editorial changes to the original wording to clarify the action to be taken
  
  
  
  

The wording used in the recommendations in this guideline (for example words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation) and is defined at the end of the "Major Recommendations" field.

Generic Principles of Care

Adults

Equip specialist settings for treating people who are severely obese with, for example, special seating and adequate weighing and monitoring equipment. Ensure hospitals have access to specialist equipment – such as larger scanners and beds – when providing general care for people who are severely obese. [2006, amended 2014]

Discuss the choice of interventions for weight management with the person. The choice of intervention should be agreed with the person. [2006, amended 2014]

Tailor the components of the planned weight management programme to the person's preferences, initial fitness, health status and lifestyle. [2006]

Children

Coordinate the care of children and young people around their individual and family needs. Comply with the approaches outlined in the Department of Health's A call to action on obesity in England .¹ [2006, amended 2014]

Aim to create a supportive environment² that helps a child who is overweight or who has obesity, and their family, make lifestyle changes. [2006, amended 2014]

Make decisions about the care of a child who is overweight or has obesity (including assessment and agreeing goals and actions) together with the child and family. Tailor interventions to the needs and preferences of the child and the family. [2006]

Ensure that interventions for children who are overweight or have obesity address lifestyle within the family and in social settings. [2006, amended 2014]

Encourage parents (or carers) to take main responsibility for lifestyle changes in children who are overweight or obese, especially if they are younger than 12 years. Take into account the age and maturity of the child, and the preferences of the child and the parents. [2006]

Adults and Children

Offer regular, non-discriminatory long-term follow-up by a trained professional. Ensure continuity of care in the multidisciplinary team through good record keeping. [2006]

Identification and Classification of Overweight and Obesity

Use clinical judgement to decide when to measure a person's height and weight. Opportunities include registration with a general practice, consultation for related conditions (such as type 2 diabetes and cardiovascular disease) and other routine health checks. [2006]

Measures of Overweight and Obesity

Use body mass index (BMI) as a practical estimate of adiposity in adults. Interpret BMI with caution because it is not a direct measure of adiposity. [2006, amended 2014]

Think about using waist circumference, in addition to BMI, in people with a BMI less than 35 kg/m².³[2006, amended 2014]

Children

Use BMI (adjusted for age and gender⁴) as a practical estimate of adiposity in children and young people. Interpret BMI with caution because it is not a direct measure of adiposity. [2006, amended 2014]

Waist circumference is not recommended as a routine measure. Use it to give additional information on the risk of developing other long-term health problems. [2006, amended 2014]

Adults and Children

Do not use bioimpedance as a substitute for BMI as a measure of general adiposity. [2006, amended 2014]

Classification of Overweight and Obesity

Adults

Define the degree of overweight or obesity in adults using the following table:

[2006]

Interpret BMI with caution in highly muscular adults as it may be a less accurate measure of adiposity in this group. Some other population groups, such as people of Asian family origin and older people, have comorbidity risk factors that are of concern at different BMIs (lower for adults of an Asian family origin and higher for older people³). Use clinical judgement when considering risk factors in these groups, even in people not classified as overweight or obese, using the classification in the recommendation above. [2006]

Base assessment of the health risks associated with being overweight or obese in adults on BMI and waist circumference as follows [2006]:

Give adults information about their classification of clinical obesity and the impact this has on risk factors for developing other long-term health problems. [2006]

Base the level of intervention to discuss with the patient initially as follows:

The level of intervention should be higher for patients with comorbidities, regardless of their waist circumference. Adjust the approach as needed, depending on the person's clinical need and potential to benefit from losing weight. [2006]

Children

Relate BMI measurement in children and young people to the United Kingdom (UK) 1990 BMI charts⁴ to give age- and gender-specific information. [2006, amended 2014]

Tailored clinical intervention should be considered for children with a BMI at or above the 91st centile, depending on the needs of the individual child and family. [2006]

Assessment

Adults and Children

Make an initial assessment (see recommendations below), then use clinical judgement to investigate comorbidities and other factors to an appropriate level of detail, depending on the person, the timing of the assessment, the degree of overweight or obesity, and the results of previous assessments. [2006]

Manage comorbidities when they are identified; do not wait until the person has lost weight. [2006]

Offer people who are not yet ready to change the chance to return for further consultations when they are ready to discuss their weight again and willing or able to make lifestyle changes. Give them information on the benefits of losing weight, healthy eating and increased physical activity. [2006]

Recognise that surprise, anger, denial or disbelief about their health situation may diminish people's ability or willingness to change. Stress that obesity is a clinical term with specific health implications, rather than a question of how people look; this may reduce any negative feelings.

During the consultation:

• Assess the person's view of their weight and the diagnosis, and possible reasons for weight gain.


• Explore eating patterns and physical activity levels.


• Explore any beliefs about eating, physical activity and weight gain that are unhelpful if the person wants to lose weight.


• Be aware that people from certain ethnic and socioeconomic backgrounds may be at greater risk of obesity, and may have different beliefs about what is a healthy weight and different attitudes towards weight management.


• Find out what the person has already tried and how successful this has been, and what they learned from the experience.


• Assess the person's readiness to adopt changes.


• Assess the person's confidence in making changes. [2006, amended 2014]

Give people and their families and/or carers information on the reasons for tests, how the tests are done, and their results and meaning. If necessary, offer another consultation to fully explore the options for treatment or discuss test results. [2006, amended 2014]

Adults

Take measurements (see recommendations above) to determine degree of overweight or obesity and discuss the implications of the person's weight. Then, assess:

• Any presenting symptoms


• Any underlying causes of being overweight or obese


• Eating behaviours


• Any comorbidities (for example type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea)


• Any risk factors assessed using lipid profile (preferably done when fasting), blood pressure measurement and glycosylated haemoglogin (HbA1c) measurement


• The person's lifestyle (diet and physical activity)


• Any psychosocial distress


• Any environmental, social and family factors, including family history of overweight and obesityand comorbidities


• The person's willingness and motivation to change lifestyle


• The potential of weight loss to improve health


• Any psychological problems⁵


• Any medical problems and medication


• The role of family and care workers in supporting individuals with learning disabilities to make lifestyle changes [2006, amended 2014]

Consider referral to tier 3 services⁶ if:

• The underlying causes of being overweight or obese need to be assessed


• The person has complex disease states or needs that cannot be managed adequately in tier 2 (for example, the additional support needs of people with learning disabilities)


• Conventional treatment has been unsuccessful


• Drug treatment is being considered for a person with a BMI of more than 50 kg/m²


• Specialist interventions (such as a very-low-calorie diet) may be needed


• Surgery is being considered [2006, amended 2014]

Children

Assessment of comorbidity should be considered for children with a BMI at or above the 98th centile. [2006]

Take measurements to determine degree of overweight or obesity and raise the issue of weight with the child and family, then assess:

• Presenting symptoms and underlying causes of being overweight or obese


• Willingness and motivation to change


• Comorbidities (such as hypertension, hyperinsulinaemia, dyslipidaemia, type 2 diabetes, psychosocial dysfunction and exacerbation of conditions such as asthma)


• Any risk factors assessed using lipid profile (preferably done when fasting) blood pressure measurement and HbA1c measurement


• Psychosocial distress, such as low self-esteem, teasing and bullying⁵


• Family history of being overweight or obese and comorbidities


• The child and family's willingness and motivation to change lifestyle


• Lifestyle (diet and physical activity)


• Environmental, social and family factors that may contribute to being overweight or obese, and the success of treatment


• Growth and pubertal status


• Any medical problems and medication


• The role of family and care workers in supporting individuals with learning disabilities to make lifestyle changes [2006, amended 2014]

Consider referral to an appropriate specialist for children who are overweight or obese and have significant comorbidities or complex needs (for example, learning disabilities or other additional support needs). [2006, amended 2014]

In tier 3 services, assess associated comorbidities and possible causes for children and young people who are overweight or who have obesity. Use investigations such as:

• Blood pressure measurement


• Lipid profile, preferably while fasting


• Fasting insulin


• Fasting glucose levels and oral glucose tolerance test


• Liver function


• Endocrine function

Interpret the results of any tests used in the context of how overweight or obese the child is, the child's age, history of comorbidities, possible genetic causes and any family history of metabolic disease related to being overweight or obese. [2006, amended 2014]

Make arrangements for transitional care for children and young people who are moving from paediatric to adult services. [2006]

Lifestyle Interventions

Adults and Children

Multicomponent interventions are the treatment of choice. Ensure weight management programmes include behaviour change strategies (see recommendations below) to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet, and reduce energy intake. [2006, amended 2014]

When choosing treatments, take into account:

• The person's individual preference and social circumstance and the experience and outcome of previous treatments (including whether there were any barriers)


• The person's level of risk, based on BMI and, where appropriate, waist circumference (see recommendations above)


• Any comorbidities [2006, amended 2014]

Document the results of any discussion. Keep a copy of the agreed goals and actions (ensure the person also does this), or put this in the person's notes. [2006, amended 2014]

Offer support depending on the person's needs, and be responsive to changes over time. [2006]

Ensure any healthcare professionals who deliver interventions for weight management have relevant competencies and have had specific training. [2006, amended 2014]

Provide information in formats and languages that are suited to the person. Use everyday, jargon-free language and explain any technical terms when talking to the person and their family or carers. Take into account the person's:

• Age and stage of life


• Gender


• Cultural needs and sensitivities


• Ethnicity


• Social and economic circumstances


• Specific communication needs (for example because of learning disabilities, physical disabilities or cognitive impairments due to neurological conditions) [2006, amended 2014]

Praise successes – however small – at every opportunity to encourage the person through the difficult process of changing established behaviour. [2006]

Give people who are overweight or obese, and their families and/or carers, relevant information on:

• Being overweight and obesity in general, including related health risks


• Realistic targets for weight loss; for adults, please see the NICE guideline on managing overweight and obesity in adults  (NICE public health guideline 53)


• The distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; advise them that the change from losing weight to maintenance typically happens after 6 to 9 months of treatment


• Realistic targets for outcomes other than weight loss, such as increased physical activity and healthier eating


• Diagnosis and treatment options


• Healthy eating in general⁷


• Medication and side effects


• Surgical treatments


• Self-care


• Voluntary organisations and support groups and how to contact them

Ensure there is adequate time in the consultation to provide information and answer questions. [2006, amended 2014]

If a person (or their family or carers) does not feel this is the right time for them to take action, explain that advice and support will be available in the future whenever they need it. Provide contact details so that the person can get in touch when they are ready. [2006, amended 2014]

Adults

Encourage the person's partner or spouse to support any weight management programme. [2006]

Base the level of intensity of the intervention on the level of risk and the potential to gain health benefits (see recommendation above). [2006]

Children

Be aware that the aim of weight management programmes for children and young people can vary. The focus may be on either weight maintenance or weight loss, depending on the person's age and stage of growth. [2006, amended 2014]

Encourage parents of children and young people who are overweight or obese to lose weight if they are also overweight or obese. [2006]

Behavioural Interventions

Adults and Children

Deliver any behavioural intervention with the support of an appropriately trained professional. [2006]

Adults

Include the following strategies in behavioural interventions for adults, as appropriate:

• Self-monitoring of behaviour and progress


• Stimulus control


• Goal setting


• Slowing rate of eating


• Ensuring social support


• Problem solving


• Assertiveness


• Cognitive restructuring (modifying thoughts)


• Reinforcement of changes


• Relapse prevention


• Strategies for dealing with weight regain [2006]

Children

Include the following strategies in behavioural interventions for children, as appropriate:

• Stimulus control


• Self-monitoring


• Goal setting


• Rewards for reaching goals


• Problem solving

Give praise to successes and encourage parents to role-model desired behaviours. [2006, amended 2014]

Physical Activity

Adults

Encourage adults to increase their level of physical activity even if they do not lose weight as a result, because of the other health benefits it can bring (for example, reduced risk of type 2 diabetes and cardiovascular disease). Encourage adults to do at least 30 minutes of moderate or greater intensity physical activity on 5 or more days a week. The activity can be in 1 session or several sessions lasting 10 minutes or more. [2006]

Advise that to prevent obesity, most people may need to do 45 to 60 minutes of moderate-intensity activity a day, particularly if they do not reduce their energy intake. Advise people who have been obese and have lost weight that they may need to do 60 to 90 minutes of activity a day to avoid regaining weight. [2006]

Encourage adults to build up to the recommended activity levels for weight maintenance, using a managed approach with agreed goals.

Recommend types of physical activity, including:

• Activities that can be incorporated into everyday life, such as brisk walking, gardening or cycling⁸


• Supervised exercise programmes


• Other activities, such as swimming, aiming to walk a certain number of steps each day, or stair climbing

[2006]

Take into account the person's current physical fitness and ability for all activities. Encourage people to also reduce the amount of time they spend inactive, such as watching television, using a computer or playing video games. [2006]

Children

Encourage children and young people to increase their level of physical activity, even if they do not lose weight as a result, because of the other health benefits exercise can bring (for example, reduced risk of type 2 diabetes and cardiovascular disease). Encourage children to do at least 60 minutes of moderate or greater intensity physical activity each day. The activity can be in 1 session or several sessions lasting 10 minutes or more. [2006]

Be aware that children who are already overweight may need to do more than 60 minutes' activity. [2006, amended 2014]

Encourage children to reduce inactive behaviours, such as sitting and watching television, using a computer or playing video games. [2006]

Give children the opportunity and support to do more exercise in their daily lives (for example, walking, cycling, using the stairs and active play⁸). Make the choice of activity with the child, and ensure it is appropriate to the child's ability and confidence. [2006]

Give children the opportunity and support to do more regular, structured physical activity (for example football, swimming or dancing). Make the choice of activity with the child, and ensure it is appropriate to the child's ability and confidence. [2006]

Dietary

Adults and Children

Tailor dietary changes to food preferences and allow for a flexible and individual approach to reducing calorie intake. [2006]

Do not use unduly restrictive and nutritionally unbalanced diets, because they are ineffective in the long term and can be harmful. [2006, amended 2014]

Encourage people to improve their diet even if they do not lose weight, because there can be other health benefits. [2006]

Adults

The main requirement of a dietary approach to weight loss is that total energy intake should be less than energy expenditure. [2006]

Diets that have a 600 kcal/day deficit (that is, they contain 600 kcal less than the person needs to stay the same weight) or that reduce calories by lowering the fat content (low-fat diets), in combination with expert support and intensive follow-up, are recommended for sustainable weight loss. [2006]

Consider low-calorie diets (800–1600 kcal/day), but be aware these are less likely to be nutritionally complete. [2006, amended 2014]

Do not routinely use very-low-calorie diets (800 kcal/day or less) to manage obesity (defined as BMI over 30). [new 2014]

Only consider very-low-calorie diets, as part of a multicomponent weight management strategy, for people who are obese and who have a clinically-assessed need to rapidly lose weight (for example, people who need joint replacement surgery or who are seeking fertility services). Ensure that:

• The diet is nutritionally complete


• The diet is followed for a maximum of 12 weeks (continuously or intermittently)


• The person following the diet is given ongoing clinical support [new 2014]

Before starting someone on a very-low-calorie diet as part of a multicomponent weight management strategy:

• Consider counselling and assess for eating disorders or other psychopathology to make sure the diet is appropriate for them.


• Discuss the risks and benefits with them.


• Tell them that this is not a long-term weight management strategy, and that regaining weight may happen and is not because of their own or their clinician's failure.


• Discuss the reintroduction of food following a liquid diet with them. [new 2014]

Provide a long-term multicomponent strategy to help the person maintain their weight after the use of a very-low-calorie diet (see recommendation above). [new 2014]

Encourage people to eat a balanced diet in the long term, consistent with other healthy eating advice⁷. [2006, amended 2014]

Children

A dietary approach alone is not recommended. It is essential that any dietary recommendations are part of a multicomponent intervention. [2006]

Any dietary changes should be age appropriate and consistent with healthy eating advice. [2006]

For overweight and obese children and young people, total energy intake should be below their energy expenditure. Changes should be sustainable. [2006, amended 2014]

Pharmacological Interventions

Adults

Consider pharmacological treatment only after dietary, exercise and behavioural approaches have been started and evaluated. [2006]

Consider drug treatment for people who have not reached their target weight loss or have reached a plateau on dietary, activity and behavioural changes. [2006]

Make the decision to start drug treatments after discussing the potential benefits and limitations with the person, including the mode of action, adverse effects and monitoring requirements, and the potential impact on the person's motivation. Make arrangements for appropriate healthcare professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies when drug treatment is prescribed. Provide information on patient support programmes. [2006, amended 2014]

Children

Drug treatment is not generally recommended for children younger than 12 years. [2006]

In children younger than 12 years, drug treatment may be used only in exceptional circumstances, if severe comorbidities are present. Prescribing should be started and monitored only in specialist paediatric settings. [2006, amended 2014]

In children aged 12 years and older, treatment with orlistat⁹ is recommended only if physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities are present. Treatment should be started in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group. [2006, amended 2014]

Do not give orlistat to children for obesity unless prescribed by a multidisciplinary team with expertise in:

• Drug monitoring


• Psychological support


• Behavioural interventions


• Interventions to increase physical activity


• Interventions to improve diet [2006, amended 2014]

Drug treatment may be continued in primary care for example with a shared care protocol if local circumstances and/or licensing allow. [2006, amended 2014]

Continued Prescribing and Withdrawal

Adults and Children

Pharmacological treatment may be used to maintain weight loss rather than to continue to lose weight. [2006]

If there is concern about micronutrient intake adequacy, a supplement providing the reference nutrient intake for all vitamins and minerals should be considered, particularly for vulnerable groups such as older people (who may be at risk of malnutrition) and young people (who need vitamins and minerals for growth and development). [2006]

Offer support to help maintain weight loss to people whose drug treatment is being withdrawn; if they did not reach their target weight, their self-confidence and belief in their ability to make changes may be low. [2006]

Adults

Monitor the effect of drug treatment and reinforce lifestyle advice and adherence through regular review. [2006, amended 2014]

Consider withdrawing drug treatment in people who have not reached weight loss targets (see recommendation below for details). [2006]

Rates of weight loss may be slower in people with type 2 diabetes, so less strict goals than those for people without diabetes may be appropriate. Agree the goals with the person and review them regularly. [2006]

Only prescribe orlistat as part of an overall plan for managing obesity in adults who meet one of the following criteria:

• A BMI of 28 kg/m² or more with associated risk factors


• A BMI of 30 kg/m² or more [2006]

Continue orlistat therapy beyond 3 months only if the person has lost at least 5% of their initial body weight since starting drug treatment (see also recommendation above for advice on targets for people with type 2 diabetes). [2006]

Make the decision to use drug treatment for longer than 12 months (usually for weight maintenance) after discussing potential benefits and limitations with the person. [2006]

The co-prescribing of orlistat with other drugs aimed at weight reduction is not recommended. [2006]

Children

If orlistat⁹ is prescribed for children, a 6- to 12-month trial is recommended, with regular review to assess effectiveness, adverse effects and adherence. [2006, amended 2014]

Surgical Interventions

Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:

• They have a BMI of 40 kg/m² or more, or between 35 kg/m² and 40 kg/m² and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.


• All appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss.


• The person has been receiving or will receive intensive management in a tier 3 service¹⁰.


• The person is generally fit for anaesthesia and surgery.


• The person commits to the need for long-term follow-up.

See recommendations below for additional criteria to use when assessing children and adults. See also recommendations below for additional criteria for people with type 2 diabetes. [2006, amended 2014]

The hospital specialist and/or bariatric surgeon should discuss the following with people who are severely obese if they are considering surgery to aid weight reduction:

• The potential benefits


• The longer-term implications of surgery


• Associated risks


• Complications


• Perioperative mortality

The discussion should also include the person's family, as appropriate. [2006, amended 2014]

Choose the surgical intervention jointly with the person, taking into account:

• The degree of obesity


• Comorbidities


• The best available evidence on effectiveness and long-term effects


• The facilities and equipment available


• The experience of the surgeon who would perform the operation [2006]

Provide regular, specialist postoperative dietetic monitoring, including:

• Information on the appropriate diet for the bariatric procedure


• Monitoring of the person's micronutrient status


• Information on patient support groups


• Individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance [2006]

Arrange prospective audit so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.¹¹ [2006, amended 2014]

The surgeon in the multidisciplinary team should:

• Have had a relevant supervised training programme


• Have specialist experience in bariatric surgery


• Submit data for a national clinical audit scheme¹¹ [2006, amended 2014]

Adults

In addition to the criteria listed above, bariatric surgery is the option of choice (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m² when other interventions have not been effective. [2006, amended 2014]

Orlistat may be used to maintain or reduce weight before surgery for people who have been recommended surgery as a first-line option, if it is considered that the waiting time for surgery is excessive. [2006, amended 2014]

Surgery for obesity should be undertaken only by a multidisciplinary team that can provide:

• Preoperative assessment, including a risk-benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s)


• Information on the different procedures, including potential weight loss and associated risks


• Regular postoperative assessment, including specialist dietetic and surgical follow up (see recommendation under "Follow-up Care" below)


• Management of comorbidities


• Psychological support before and after surgery


• Information on, or access to, plastic surgery (such as apronectomy) when appropriate


• Access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for people undergoing bariatric surgery, and staff trained to use them [2006]

Carry out a comprehensive preoperative assessment of any psychological or clinical factors that may affect adherence to postoperative care requirements (such as changes to diet) before performing surgery. [2006, amended 2014]

Revisional surgery (if the original operation has failed) should be undertaken only in specialist centres by surgeons with extensive experience because of the high rate of complications and increased mortality. [2006]

Children

Surgical intervention is not generally recommended in children or young people. [2006]

Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity. [2006]

Surgery for obesity should be undertaken only by a multidisciplinary team that can provide paediatric expertise in:

• Preoperative assessment, including a risk-benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s)


• Information on the different procedures, including potential weight loss and associated risks


• Regular postoperative assessment, including specialist dietetic and surgical follow up


• Management of comorbidities


• Psychological support before and after surgery


• Information on or access to plastic surgery (such as apronectomy) when appropriate


• Access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for children and young people undergoing bariatric surgery, and staff trained to use them [2006]

Coordinate surgical care and follow-up around the child or young person and their family's needs. Comply with the approaches outlined in the Department of Health's A call to action on obesity in England . [2006, amended 2014]

Ensure all young people have had a comprehensive psychological, educational, family and social assessment before undergoing bariatric surgery. [2006, amended 2014]

Perform a full medical evaluation, including genetic screening or assessment before surgery to exclude rare, treatable causes of obesity. [2006]

Bariatric Surgery for People with Recent-onset Type 2 Diabetes

Offer an expedited assessment for bariatric surgery to people with a BMI of 35 or over who have recent-onset type 2 diabetes¹² as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent). [new 2014]

Consider an assessment for bariatric surgery for people with a BMI of 30–34.9 who have recent-onset type 2 diabetes◄ BACK