Jellinek as far back as 1941 advocated the matching of patients and treatment; by 1950, an experiment in matching patients to four treatment programs had been carried out (Wallerstein, 1956). Since then, research in treatment matching in alcoholism has accelerated, and several reports have defined many of the relevant matching variables (IOM, 1990). The field of obesity has lagged behind that of alcoholism in considering the matching of patients to treatments, probably as a reflection of the fact that self-treatment (i.e., voluntary dieting and exercise) is widely practiced and thought to be generally applicable to most obese people.

SCHEMES FOR MATCHING IN THE OBESITY FIELD

It was not until the early 1980s that the first efforts at matching in obesity were reported. In 1981, Garrow proposed a system of classification of obesity as the necessary precondition for matching, together with treatments appropriate for the different ''grades" of obesity. Garrow's classification was based on the body mass index (BMI) and divided obese persons into four groups: (1) Grade III, BMI > 40; (2) Grade II, BMI 30–40; (3) Grade I, BMI 25–29.9; and (4) Grade 0, BMI 20–24.9. Treatments were prescribed according to the grade of obesity, from surgery for Grade III, through dietary measures of greater or lesser stringency and the possible use of medication for intermediate grades, to reassurance about body weight for Grade 0.

Independent of Garrow, Stunkard (1984) proposed a similar matching scheme. His classification also divided obese persons on the basis of their weight, defining mild obesity as a percentage of overweight of less than 40, moderate obesity as 40–99 percent overweight, and severe obesity as 100 percent or more overweight. He matched these levels of obesity with treatment, recommending that severe obesity be treated with surgery, moderate obesity with diet and behavior modification under medical supervision, and mild obesity with behavior modification under lay auspices, as carried out by some commercial organizations.

A third effort at matching in obesity was published by Brownell and Wadden (1991). In this model, the authors divided obesity into four levels, once again assessed only in terms of percentage of overweight. The authors provided a greater number of treatment options, however, divided into five "steps" moving from self-directed diet programs and self-help groups for the thinnest persons (5–20 percent overweight) to, as in the earlier schemes, surgery for the most obese (at least 100 percent overweight). Furthermore, they provided a list of individual factors and program factors to be used in the matching decision. The model is shown in Figure 5-1.



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