Appendix D: Clinical Elements by Condition

Evaluation of English and Spanish Health Information on the Internet

APPENDIX D: Clinical Elements by Condition

Breast Cancer
Condition-Related Topic	Condition-Related Clinical Elements
1. Assessment of Breast Cancer Risk and Use of Tamoxifen for Risk Reduction	Risk factors for breast cancer include a family or personal history of breast cancer; early menarche; pregnancy history, and a history of breast biopsies. In the short run (meaning up to 5 years), tamoxifen reduces breast cancer risk in high-risk women.
2. Screening for Breast Cancer	Women over 50 should have mammograms every one to two years. Early detection of breast cancer improves outcomes. Most breast cancers occur in women without a family history. There is a lack of consensus about the need for or appropriate interval of mammography in women from age 40-49 years.
3. Evaluation of a Palpable Breast Mass	New breast lumps should be brought to the attention of a physician. Mammography and ultrasound are useful in evaluating lumps. A negative mammogram does not eliminate the need for further evaluation. A persistent, non-cystic (non-fluid filled) breast mass felt by a physician should be biopsied.
4. Treatment, Including Primary Treatment and Availability of Clinical Trials for Treatment of Advanced Cancers	Mastectomy and lumpectomy plus radiation are equivalent treatments for early stage breast cancer. Patient preferences should be considered in treatment decisions around mastectomy versus lumpectomy plus radiation. Breast reconstruction is available for women who have mastectomy. Clinical trials are available for women with advanced cancer. Some information about finding clinical trials is given.
5. Alternatives to Standard Medical and Surgical Treatments for Breast Cancer	Alternative therapies to treat breast cancer have generally not been subjected to rigorous scientific studies. Alternative therapies should not be used as a substitute for proven effective treatments. Your physician should be informed of any alternative treatments you are using, including herbs, supplements, and over-the-counter medications.

APPENDIX D: Clinical Elements by Condition (cont.)

Childhood Asthma

Condition-Related Topic Condition-Related Clinical Elements

1. Symptoms of Pediatric Asthma A child with asthma can experience the following symptoms: 1) cough, 2) wheezing, 3) chest tightness, 4) shortness of breath or difficulty breathing or 5) an "asthma attack" (pronounced or prolonged presence of these symptoms). (Please note a web site that does not include the most important and noticeable symptoms #2, 4, 5 should not be rated as "more than minimally addressed.")
These symptoms can be worse at night, triggered by exercise, environmental irritants, changes in weather, viral illness, or can occur spontaneously at rest.
Children with asthma can have intermittent symptoms (twice a week or less) or persistent symptoms (more than twice a week).
Children with intermittent symptoms may have a severe exacerbation.

2. Symptoms Suggestive of Uncontrolled Pediatric Asthma Children with intermittent symptoms (day symptoms twice a week or less and/or night symptoms twice a month or less) are considered "controlled."
with persistent symptoms (day symptoms and/or need to use a rescue medication more than twice a week or waking up with symptoms during the night more than twice a month) are "not controlled."

3. Pediatric Asthma- Therapeutic Modalities and Associated Side Effects Bronchodilator medications (e.g. albuterol, Proventil, Ventolin) open the airways (breathing passages.) They are used as "quick relief" or "rescue" medications for patients whose symptoms are intermittent (as defined in Topic Area 1.)
Inhaled corticosteroids (e.g. beclomethasone, flunisolide, triamcinolone, Beclovent, Vanceril, Flovent, Azmacort,) and cromolyn (Intal) are two kinds of inhaled medications that reduce inflammation in the airways. They are used as long-term treatments for patients whose symptoms are persistent or uncontrolled.
A spacer device will improve delivery of inhaled medications to the lungs. Such devices are required for young children and are strongly recommended for older children and adolescents.
Peak flow monitoring is a useful way for patients to recognize early signs of worsening asthma.
Oral steroids are effective for short-term exacerbations but have significant side effects over the long term.
Inhaled steroids, taken in usual doses, do not affect children's growth. Uncontrolled asthma can retard a child's growth.
Alternative therapies for asthma (e.g. herbal remedies and chiropractic manipulation) have not been shown to be effective.
Anti-leukotrienes are a new class drug that might be useful as an add-on to inhaled steroids or to prevent exercise symptoms in children over age 6. The safety and efficacy of these drugs in children under 6 years of age has not been demonstrated.

4. Initial Management of Severe Pediatric Asthma Some children can die of asthma, especially if the early warning signs of a severe asthma attack are missed.
Signs of a life-threatening asthma episode include: 1) very difficult breathing, 2) shortness of breath at rest, 3) uncontrolled coughing, 4) severe chest tightness, 5) blueness around the lips or nails, 6) difficulty talking, 7) extreme tiredness, fatigue or 8) unresponsiveness. (To warrant a score of two under coverage, the material must include mention of symptoms # 1,2, 4, 5, 8).
"Immediate home care for a severe asthma attack includes prompt administration of the child's quick-relief or rescue medication.
If symptoms of a severe asthma attack are not relieved within 10 minutes or if the child's symptoms worsen, the caretaker should call 911.

5. Pediatric Asthma -- Risk Factors Certain indoor allergens and irritants (e.g., tobacco smoke, dust mites, cockroach allergens, cat hair) have been shown to cause worsening of acute asthma in children who are sensitive to these factors, but not to cause asthma per se.
Although pollution is not a proven cause of asthma, persons with asthma can experience more asthma exacerbations on high pollution days.
Other indoor allergens or irritants such as mold, animal dander other than cat, pollen, strong odors, etc. have been reported to be associated with worsening asthma symptoms. However, there is scientific uncertainty about the role of these factors. (For full credit, must mention both the potential role of these allergens/irritants and uncertainty about their importance.)
Allergens or irritants that trigger a child's asthma can usually be identified through a careful medical history. Blood and skin tests conducted by an allergy specialist can also be helpful.
Most children being considered for immunotherapy should be evaluated and followed by an allergy specialist.
Allergy immunotherapy for children with asthma should only be considered when: 1) there is clear evidence of a relationship between symptoms and exposure to an unavoidable allergen to which the child is sensitive, 2) symptoms occur all year or during a major portion of the year, 3) the symptoms are not controlled with medications. (All 3 quired for full credit.)
Families who are sensitive to tobacco smoke, dust mites, cockroach antigens, or cats should undertake vigorous exposure reduction strategies. (Site must suggest any of the specific exposure reduction strategies listed below* for 3/4 of these irritants for full credit.)

6. Etiology and Risk Factors The cause of asthma is not known.
Most experts speculate that asthma may be caused by a combination of genetic (hereditary) and environmental factors (exposures).
Asthma is not contagious and is not caused by psychological or psychiatric disturbances.
Although asthma medications can control symptoms, asthma is not curable given current science.

7. Pediatric Asthma -- Expectations from Therapy In 80-85% of cases, children with asthma can be symptom-free if they follow a preventive medication regimen and/or avoid allergens or irritants to which they are sensitive.
Even if 100% freedom from symptoms is not possible, the disease can be controlled so that the child experiences minimal symptoms during the day and night.
Children with asthma should be able to participate in normal activities (school, play, etc.) and parents should not have to lose work or sleep time because of children's asthma symptoms.

APPENDIX D: Clinical Elements by Condition (cont.)

Depression

Condition-Related Topic Condition-Related Clinical Elements

1. Symptoms of Depression The primary symptoms of depression are persistent low mood, loss of interest and enjoyment, and reduced energy lasting at least two weeks.
Other symptoms of depression include significant weight, sleep and appetite changes, anxiety, feelings of worthlessness or inappropriate guilt, diminished ability to think or concentrate or indecisiveness, recurrent thoughts of death or suicidal ideation, apathy or irritability. A person may have a depressive disorder without having all of these symptoms.
In older patients (defined as 65 years or older), depression may not always present with low mood as seen in younger patients. Instead, patients may seem apathetic and uninterested in normal activities. Anxiety and memory impairment may also be the principal presenting symptoms.
Depression should not be regarded as a normal part of aging.

2. Treatments for Depression Effective treatments for depression include prescription antidepressant drugs, specific psychological treatments (cognitive therapy, cognitive behavioral therapy and interpersonal therapy), combination therapy and electroconvlusive therapy (ECT.)
No antidepressant is superior to another in efficacy or time to response. The choice of medication is based upon side effect profile or prior response.
St. John's Wort (hypericum perforatum) may be an effective treatment for mild depression. However, because of reported drug interactions, patients who are taking other prescription medicines should consult with a physician before starting this preparation.

3. Antidepressant Medications Antidepressant medications typically begin to work within several weeks. However, many patients do not experience substantial benefits for 4-6 weeks, and it may take 3-4 months before people on antidepressants feel completely better.
Patients with a single episode of acute depression who experience initial improvement should continue to take the medication, usually for 6-12 months after they feel completely better in order to keep feeling well.
With antidepressant medicines, many people have some side effects early in treatment (in the first 4 to 6 weeks). Most side effects get better in the first month. For some people, the side effects can be bad enough to stop the medicine. Common side effects include anxiety, sexual dysfunction, sleepiness, trouble sleeping, weight gain/loss, restlessness and nausea.

4. Role of Counseling For mild to moderate depression, prescriptive antidepressant drugs and specific psychological therapies are equally effective.
For moderate to severe depression, prescription antidepressant drugs are more effective than psychological therapies.
For severe depression, the combination of drug therapy with psychological treatment is probably more effective than psychological therapy alone.

5. Suicidal Ideation People who have suicidal thoughts but are confident they will not carry out suicide should obtain a medical or psychiatric evaluation promptly.
People with suicidal thoughts who think there is any chance they might attempt suicide should seek emergency evaluation and help from their physician or at an emergency room.

6. Professional Evaluation of Depression The best person see for the evaluation of and treatment for depression is uncertain. To date, no definitive scientific studies have proven which one is best.
For mild depression, both the initial evaluation and subsequent treatment can be provided by a primary care doctor, psychiatrist or psychologist/therapist.
For moderate depression, an individual should either see a primary care physician or a psychiatrist for an initial evaluation; subsequent treatment may be provided by either the evaluating physician or a psychologist/therapist.
For severe depression, an individual should probably see a psychiatrist or a primary care doctor for an initial evaluation; treatment should be by a physician and possibly an adjunctive therapist.

7. Etiology -- Depression The causes of depression are uncertain but probably results from a combination of genetic predisposition, and childhood and current psychosocial adversity.

APPENDIX D: Clinical Elements by Condition (cont.)

Obesity

Condition-Related Topic Condition-Related Clinical Elements

1. Indications for Weight Loss, Definitions of Overweight and Obesity Body mass index (BMI, weight in kilograms squared/height in meters squared) is a useful way to determine whether someone is overweight or obese.
There is a distinction between overweight and obesity; overweight is currently defined as BMI between 25 and 29.9; obesity is defined as BMI>=30.
Growing evidence suggests that these thresholds may be too high for certain non-Caucasian populations (e.g., Chinese, Japanese, Hispanics).
Waist circumference is by itself predictive of future morbidity; high-risk cutoffs are 35 inches for women and 40 inches for men.
The health risks of obesity also depend upon disease conditions (e.g. CAD, DM), cardiovascular risk factors (e.g., family history, LDL cholesterol, hypertension), and other obesity-associated diseases and risk factors (e.g., gallstones, degenerative joint disease).
Treatment is indicated when the patient meets criteria for obesity, or when the patient meets criteria for overweight and the patient has: (1) established cardiovascular disease or diabetes; (2) >=2 other risk factors including hypertension, dyslipidemia, smoking, family history of heart disease, age>=45 for men or 55 for women; or (3) a high waist circumference (>35 inches for women or >40 inches for men).

2. Health Risks of Being Overweight and Obese There is an increase in mortality as BMI exceeds 25; the risk increases rapidly above a BMI of 30.
Important morbidities associated with obesity include diabetes mellitus, hypertension, abnormal blood lipids, coronary artery disease, and sleep apnea.
Other morbidities include gastro-esophageal reflux disease, gallstones, urinary stress incontinence, and osteoarthritis.
In addition to medical morbidities, overweight/obesity can produce limitations in mobility, reduced functional status, and lower overall quality of life.

3. Risks and Benefits of Low Carbohydrate, High Protein Diets The benefits of Atkins-type diets include: a. Good short-term weight loss b. Less hunger than a standard low fat diet c. Better short-term control of insulin-resistance states, including Type II diabetes and hypertension.
Initial rapid weight loss is mostly water loss.
The long-term safety (beyond 6 months) of these diets have not been established.

4. Value of Physical Activity for Weight Loss, Maintenance and General Health Regular physical activity results in modest weight loss, especially when combined with a low calorie diet.
Physical activity is more effective at maintaining current weight than at reducing weight.
Physical activity benefits general health and fitness independent of weight loss.
Physical activity benefits some obesity-related problems (e.g., diabetes and hypertension), independent of weight loss.

5. Availability of Drugs Approved for Weight Loss Weight loss drugs are an FDA approved option for patients with a BMI >=27 (with concomitant risk factors) or >=30 (without risk factors).
FDA approved prescription drugs for weight loss include sibutramine (Meridia), orlistat (Xenical), and phentermine (Fastin).
Phenylpropanolamine (Dexatrim, Acutrim) is an OTC weight loss agent approved for short-term use (<=3 months).
Phenylpropanolamine (Dexatrim, Acutrim) has been associated with strokes (although the magnitude of the stroke risk is not established).

6. Indications, Risks and Benefits of Weight Loss Surgery Weight loss surgery should be considered when the BMI is 40 or higher, or when it is 35-39.9 in the presence of medical co-morbidities (e.g., diabetes, known cardiovascular disease, severe degenerative joint disease, hypertension, GERD, sleep apnea).
Gastric restrictive procedures (e.g. vertical banded gastroplasty), gastric bypass, and malabsorptive procedures (e.g. biliopancreatic diversion) have been shown to be effective.
Patients can achieve substantial weight loss, often over 100 pounds or more.
Gastric bypass is somewhat more effective (in terms of weight loss) than vertical banded gastroplasty.
Death and major complication rates following surgery are approximately equal for gastric bypass and vertical banded gastroplasty. Operative mortality is less than 0.5%, morbidity is approximately 5%, incisional hernia rate is approximately 5%, and small bowel obstruction occurs in 2% of cases.

7. Safety and Effectiveness of Dietary Supplements Containing Ephedra plus Caffeine Ephedrine (ephedra) plus caffeine has been shown to be effective as a weight loss supplement.
Several safety concerns remain, especially for patients with co-morbid conditions that might be worsened by sympathomimetic effects.
Patients who have heart disease or hypertension should consult a physician before taking this combination.

Table of Contents
Appendix C
Appendix E

Childhood Asthma
Condition-Related Topic	Condition-Related Clinical Elements
1. Symptoms of Pediatric Asthma	A child with asthma can experience the following symptoms: 1) cough, 2) wheezing, 3) chest tightness, 4) shortness of breath or difficulty breathing or 5) an "asthma attack" (pronounced or prolonged presence of these symptoms). (Please note a web site that does not include the most important and noticeable symptoms #2, 4, 5 should not be rated as "more than minimally addressed.") These symptoms can be worse at night, triggered by exercise, environmental irritants, changes in weather, viral illness, or can occur spontaneously at rest. Children with asthma can have intermittent symptoms (twice a week or less) or persistent symptoms (more than twice a week). Children with intermittent symptoms may have a severe exacerbation.
2. Symptoms Suggestive of Uncontrolled Pediatric Asthma	Children with intermittent symptoms (day symptoms twice a week or less and/or night symptoms twice a month or less) are considered "controlled." with persistent symptoms (day symptoms and/or need to use a rescue medication more than twice a week or waking up with symptoms during the night more than twice a month) are "not controlled."
3. Pediatric Asthma- Therapeutic Modalities and Associated Side Effects	Bronchodilator medications (e.g. albuterol, Proventil, Ventolin) open the airways (breathing passages.) They are used as "quick relief" or "rescue" medications for patients whose symptoms are intermittent (as defined in Topic Area 1.) Inhaled corticosteroids (e.g. beclomethasone, flunisolide, triamcinolone, Beclovent, Vanceril, Flovent, Azmacort,) and cromolyn (Intal) are two kinds of inhaled medications that reduce inflammation in the airways. They are used as long-term treatments for patients whose symptoms are persistent or uncontrolled. A spacer device will improve delivery of inhaled medications to the lungs. Such devices are required for young children and are strongly recommended for older children and adolescents. Peak flow monitoring is a useful way for patients to recognize early signs of worsening asthma. Oral steroids are effective for short-term exacerbations but have significant side effects over the long term. Inhaled steroids, taken in usual doses, do not affect children's growth. Uncontrolled asthma can retard a child's growth. Alternative therapies for asthma (e.g. herbal remedies and chiropractic manipulation) have not been shown to be effective. Anti-leukotrienes are a new class drug that might be useful as an add-on to inhaled steroids or to prevent exercise symptoms in children over age 6. The safety and efficacy of these drugs in children under 6 years of age has not been demonstrated.
4. Initial Management of Severe Pediatric Asthma	Some children can die of asthma, especially if the early warning signs of a severe asthma attack are missed. Signs of a life-threatening asthma episode include: 1) very difficult breathing, 2) shortness of breath at rest, 3) uncontrolled coughing, 4) severe chest tightness, 5) blueness around the lips or nails, 6) difficulty talking, 7) extreme tiredness, fatigue or 8) unresponsiveness. (To warrant a score of two under coverage, the material must include mention of symptoms # 1,2, 4, 5, 8). "Immediate home care for a severe asthma attack includes prompt administration of the child's quick-relief or rescue medication. If symptoms of a severe asthma attack are not relieved within 10 minutes or if the child's symptoms worsen, the caretaker should call 911.
5. Pediatric Asthma -- Risk Factors	Certain indoor allergens and irritants (e.g., tobacco smoke, dust mites, cockroach allergens, cat hair) have been shown to cause worsening of acute asthma in children who are sensitive to these factors, but not to cause asthma per se. Although pollution is not a proven cause of asthma, persons with asthma can experience more asthma exacerbations on high pollution days. Other indoor allergens or irritants such as mold, animal dander other than cat, pollen, strong odors, etc. have been reported to be associated with worsening asthma symptoms. However, there is scientific uncertainty about the role of these factors. (For full credit, must mention both the potential role of these allergens/irritants and uncertainty about their importance.) Allergens or irritants that trigger a child's asthma can usually be identified through a careful medical history. Blood and skin tests conducted by an allergy specialist can also be helpful. Most children being considered for immunotherapy should be evaluated and followed by an allergy specialist. Allergy immunotherapy for children with asthma should only be considered when: 1) there is clear evidence of a relationship between symptoms and exposure to an unavoidable allergen to which the child is sensitive, 2) symptoms occur all year or during a major portion of the year, 3) the symptoms are not controlled with medications. (All 3 quired for full credit.) Families who are sensitive to tobacco smoke, dust mites, cockroach antigens, or cats should undertake vigorous exposure reduction strategies. (Site must suggest any of the specific exposure reduction strategies listed below* for 3/4 of these irritants for full credit.)
6. Etiology and Risk Factors	The cause of asthma is not known. Most experts speculate that asthma may be caused by a combination of genetic (hereditary) and environmental factors (exposures). Asthma is not contagious and is not caused by psychological or psychiatric disturbances. Although asthma medications can control symptoms, asthma is not curable given current science.
7. Pediatric Asthma -- Expectations from Therapy	In 80-85% of cases, children with asthma can be symptom-free if they follow a preventive medication regimen and/or avoid allergens or irritants to which they are sensitive. Even if 100% freedom from symptoms is not possible, the disease can be controlled so that the child experiences minimal symptoms during the day and night. Children with asthma should be able to participate in normal activities (school, play, etc.) and parents should not have to lose work or sleep time because of children's asthma symptoms.

Depression
Condition-Related Topic	Condition-Related Clinical Elements
1. Symptoms of Depression	The primary symptoms of depression are persistent low mood, loss of interest and enjoyment, and reduced energy lasting at least two weeks. Other symptoms of depression include significant weight, sleep and appetite changes, anxiety, feelings of worthlessness or inappropriate guilt, diminished ability to think or concentrate or indecisiveness, recurrent thoughts of death or suicidal ideation, apathy or irritability. A person may have a depressive disorder without having all of these symptoms. In older patients (defined as 65 years or older), depression may not always present with low mood as seen in younger patients. Instead, patients may seem apathetic and uninterested in normal activities. Anxiety and memory impairment may also be the principal presenting symptoms. Depression should not be regarded as a normal part of aging.
2. Treatments for Depression	Effective treatments for depression include prescription antidepressant drugs, specific psychological treatments (cognitive therapy, cognitive behavioral therapy and interpersonal therapy), combination therapy and electroconvlusive therapy (ECT.) No antidepressant is superior to another in efficacy or time to response. The choice of medication is based upon side effect profile or prior response. St. John's Wort (hypericum perforatum) may be an effective treatment for mild depression. However, because of reported drug interactions, patients who are taking other prescription medicines should consult with a physician before starting this preparation.
3. Antidepressant Medications	Antidepressant medications typically begin to work within several weeks. However, many patients do not experience substantial benefits for 4-6 weeks, and it may take 3-4 months before people on antidepressants feel completely better. Patients with a single episode of acute depression who experience initial improvement should continue to take the medication, usually for 6-12 months after they feel completely better in order to keep feeling well. With antidepressant medicines, many people have some side effects early in treatment (in the first 4 to 6 weeks). Most side effects get better in the first month. For some people, the side effects can be bad enough to stop the medicine. Common side effects include anxiety, sexual dysfunction, sleepiness, trouble sleeping, weight gain/loss, restlessness and nausea.
4. Role of Counseling	For mild to moderate depression, prescriptive antidepressant drugs and specific psychological therapies are equally effective. For moderate to severe depression, prescription antidepressant drugs are more effective than psychological therapies. For severe depression, the combination of drug therapy with psychological treatment is probably more effective than psychological therapy alone.
5. Suicidal Ideation	People who have suicidal thoughts but are confident they will not carry out suicide should obtain a medical or psychiatric evaluation promptly. People with suicidal thoughts who think there is any chance they might attempt suicide should seek emergency evaluation and help from their physician or at an emergency room.
6. Professional Evaluation of Depression	The best person see for the evaluation of and treatment for depression is uncertain. To date, no definitive scientific studies have proven which one is best. For mild depression, both the initial evaluation and subsequent treatment can be provided by a primary care doctor, psychiatrist or psychologist/therapist. For moderate depression, an individual should either see a primary care physician or a psychiatrist for an initial evaluation; subsequent treatment may be provided by either the evaluating physician or a psychologist/therapist. For severe depression, an individual should probably see a psychiatrist or a primary care doctor for an initial evaluation; treatment should be by a physician and possibly an adjunctive therapist.
7. Etiology -- Depression	The causes of depression are uncertain but probably results from a combination of genetic predisposition, and childhood and current psychosocial adversity.

Obesity
Condition-Related Topic	Condition-Related Clinical Elements
1. Indications for Weight Loss, Definitions of Overweight and Obesity	Body mass index (BMI, weight in kilograms squared/height in meters squared) is a useful way to determine whether someone is overweight or obese. There is a distinction between overweight and obesity; overweight is currently defined as BMI between 25 and 29.9; obesity is defined as BMI>=30. Growing evidence suggests that these thresholds may be too high for certain non-Caucasian populations (e.g., Chinese, Japanese, Hispanics). Waist circumference is by itself predictive of future morbidity; high-risk cutoffs are 35 inches for women and 40 inches for men. The health risks of obesity also depend upon disease conditions (e.g. CAD, DM), cardiovascular risk factors (e.g., family history, LDL cholesterol, hypertension), and other obesity-associated diseases and risk factors (e.g., gallstones, degenerative joint disease). Treatment is indicated when the patient meets criteria for obesity, or when the patient meets criteria for overweight and the patient has: (1) established cardiovascular disease or diabetes; (2) >=2 other risk factors including hypertension, dyslipidemia, smoking, family history of heart disease, age>=45 for men or 55 for women; or (3) a high waist circumference (>35 inches for women or >40 inches for men).
2. Health Risks of Being Overweight and Obese	There is an increase in mortality as BMI exceeds 25; the risk increases rapidly above a BMI of 30. Important morbidities associated with obesity include diabetes mellitus, hypertension, abnormal blood lipids, coronary artery disease, and sleep apnea. Other morbidities include gastro-esophageal reflux disease, gallstones, urinary stress incontinence, and osteoarthritis. In addition to medical morbidities, overweight/obesity can produce limitations in mobility, reduced functional status, and lower overall quality of life.
3. Risks and Benefits of Low Carbohydrate, High Protein Diets	The benefits of Atkins-type diets include: a. Good short-term weight loss b. Less hunger than a standard low fat diet c. Better short-term control of insulin-resistance states, including Type II diabetes and hypertension. Initial rapid weight loss is mostly water loss. The long-term safety (beyond 6 months) of these diets have not been established.
4. Value of Physical Activity for Weight Loss, Maintenance and General Health	Regular physical activity results in modest weight loss, especially when combined with a low calorie diet. Physical activity is more effective at maintaining current weight than at reducing weight. Physical activity benefits general health and fitness independent of weight loss. Physical activity benefits some obesity-related problems (e.g., diabetes and hypertension), independent of weight loss.
5. Availability of Drugs Approved for Weight Loss	Weight loss drugs are an FDA approved option for patients with a BMI >=27 (with concomitant risk factors) or >=30 (without risk factors). FDA approved prescription drugs for weight loss include sibutramine (Meridia), orlistat (Xenical), and phentermine (Fastin). Phenylpropanolamine (Dexatrim, Acutrim) is an OTC weight loss agent approved for short-term use (<=3 months). Phenylpropanolamine (Dexatrim, Acutrim) has been associated with strokes (although the magnitude of the stroke risk is not established).
6. Indications, Risks and Benefits of Weight Loss Surgery	Weight loss surgery should be considered when the BMI is 40 or higher, or when it is 35-39.9 in the presence of medical co-morbidities (e.g., diabetes, known cardiovascular disease, severe degenerative joint disease, hypertension, GERD, sleep apnea). Gastric restrictive procedures (e.g. vertical banded gastroplasty), gastric bypass, and malabsorptive procedures (e.g. biliopancreatic diversion) have been shown to be effective. Patients can achieve substantial weight loss, often over 100 pounds or more. Gastric bypass is somewhat more effective (in terms of weight loss) than vertical banded gastroplasty. Death and major complication rates following surgery are approximately equal for gastric bypass and vertical banded gastroplasty. Operative mortality is less than 0.5%, morbidity is approximately 5%, incisional hernia rate is approximately 5%, and small bowel obstruction occurs in 2% of cases.
7. Safety and Effectiveness of Dietary Supplements Containing Ephedra plus Caffeine	Ephedrine (ephedra) plus caffeine has been shown to be effective as a weight loss supplement. Several safety concerns remain, especially for patients with co-morbid conditions that might be worsened by sympathomimetic effects. Patients who have heart disease or hypertension should consult a physician before taking this combination.