reduced by a 3- to 6-week "run-in" period during which subjects are started on ancillary therapy, including calorie restriction, behavior modification, and exercise. One can then assess the degree of commitment of the subjects and their response to the ancillary therapy prior to drug treatment. Drug treatment is then added to the ancillary therapy. Weintraub encourages use of this approach when treating obese patients with drugs for weight management.

A National Institutes of Health workshop on the pharmacological treatment of obesity concluded that "obesity drugs produce short-term weight loss and may remain effective for extended periods of time in some patients" (Atkinson and Hubbard, 1994). Nevertheless, drugs should be used as only one component of a comprehensive weight-reduction program that includes attention to diet, activity, and behavior modification. According to Silverstone (1993), these drugs should be limited to patients who are medically at risk because of their condition, among which he includes those with a BMI of 30 or greater or those with a comorbid condition.

Gastric Surgery

Because of its unique nature, the special requirements of participating patients, and the characteristics of the services implied in this type of program, the surgical treatment of obesity is a special subcategory of clinical programs. Two proven surgical procedures exist for the treatment of severe and very severe obesity: vertical banded gastroplasty and Roux-en-Y gastric bypass. Vertical banded gastroplasty consists of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. Roux-en-Y gastric bypass involves constructing a proximal gastric pouch whose outlet is a Y-shaped limb of small bowel of varying lengths (NIH, 1992). Vertical banded gastroplasty is less complex to perform and has fewer perioperative complications than gastric bypass, but produces less long-term weight loss (Sugerman et al., 1989). On the other hand, a higher risk of nutritional deficiencies exists following gastric bypass (NIH, 1992). Intestinal bypass surgery is no longer recommended as a surgical option to treat obesity (NIH, 1992).

The risk-benefit ratio must be evaluated for each patient when deciding if surgery should be utilized. Patients who have failed with nonsurgical measures and who are well informed and motivated may be considered. They must be able to participate in treatment and long-term follow-up. A BMI greater than 40 indicates the patient may be a potential candidate for surgical treatment (NIH, 1992). Patients with a BMI between 35 and 40 may be considered if they have high-risk comorbid conditions such as life-threatening cardiopulmonary problems or severe diabetes



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