A wide variety of professional societies as well as professionals at the National Institutes of Health were invited to comment on the initial draft. A conference was arranged for October 5th-6th in Washington DC so that physicians, dietitians, nurses and other health professionals could reach consensus. Final release to the media, by former Surgeon General C. Everett Koop, M.D., was set for October 29th at the National Press Club. Shape Up America!, which Dr. Koop founded, has provided substantial staff support for the effort to produce the guidelines.

Comprehensive guidelines are crucial to obesity treatment. There have been a number of attempts to develop guidelines, but the result was flawed and by now out of date. The early attempts at writing guidelines preceded our era of rapid expansion of knowledge and research on obesity; the modern discoveries were still unknown.

In the past, when obesity was not considered a disease with a genetic background, treatment guidelines reflected the opinion that modifications of "bad" behavior was all that was needed. The main responsibility was put on patients, who had to change their eating habits and exercise patterns. Today the physician also has a major role, in devising a comprehensive plan that might include obesity drugs or surgery. Other health care professionals may also play a part: dietitians, nurses, psychologists and exercise physiologists, for example. Of course, changes in diet and activity are still very important, but we now understand they are not enough to produce long term weight loss in the majority of obese people. Needed are guidelines that reflect this understanding and that evaluate all the options now available, such as very low calorie diets, surgical treatment, pharmacological treatment, diet, exercise and lifestyle change.

Guidelines also may improve the chances of obtaining reimbursement for obesity treatment. Insurance companies and Federal programs, including Medicaid and Medicare, seize upon the absence of guidelines as a pretext to deny such benefits. An insurance company contacted by the AOA explained that the lack of guidelines "makes it impossible for us to cover obesity treatment". If you pay for treatment yourself, the cost is not deductible from your income tax as a medical expense. All of this seems foolish, since obesity kills 300,000 people per year and contributes to heart attacks, strokes and other serious diseases in many more; insurers and the government ultimately pay to treat people for those conditions. Since the lack of guidelines is and excuse to deny benefits, the AOA must work to eliminate the excuse.

The process of developing guidelines for obesity treatment is painstaking. First, the committee must ensure that the guidelines are based on sound scientific principles. In winnowing the medical literature, the committee rates the quality of each paper. It is also taking care to ensure that the mode of treatment is keyed to the severity of each patient's obesity. For example, obesity surgery is recommended only for patients at the top step of the obesity scale, those with massive obesity. Drug treatment is acceptable at the middle steps, for less sever obesity, but not for those at the bottom step - the modestly overweight - unless there are special circumstances. Careful dieting and increased activity are recommended for everyone.

Distinctions among types of treatment are required because individuals' needs differ and because the various treatments entail varying degrees of risk. Surgery carries a comparatively high risk, drugs and intermediate risk, and diet and exercise a low risk. The risks of each type of treatment must be balanced against the risks of remaining overweight or obese.

The guidelines will take into account complications of obesity and recommend a logical progression of treatments in the event that the initial treatment is unsuccessful. The language will be understandable, enabling patients to discuss their care with physicians in an informed manner.