Regular readers of these pages may remotely recall that last year I complained about how BMI does not always allow us to make rational clinical decisions regarding obesity management, because measures of weight (such as BMI) do not reflect severity of obesity in a given individual. In that post, I discussed several options of further classifying obesity based on clinical parameters that would guide management.
Following the tremendous positive response on that earlier posting, I invited Dr. Robert Kushner, President of The Obesity Society, to join me in writing an article in which we propose a 5 stage system that would allow clinicians to grade obesity based on simple criteria obtained from medical history, physical examination and standard diagnostic tests.
This article is now published in the International Journal of Obesity and also provides a brief history of obesity taxonomy and classifications together with a discussion of their shortcomings.
As described in the paper, our proposal defines 5 stages of obesity ranked according to increasing severity.
STAGE 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations and/or impairment of well being.
STAGE 1: Patient has obesity-related subclinical risk factor(s) (e.g., borderline hypertension, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well being.
STAGE 2: Patient has established obesity-related chronic disease(s) (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or well being.
STAGE 3: Patient has established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitation(s) and/or impairment of well being.
STAGE 4: Patient has severe (potentially end-stage) disability/ies from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitation(s) and/or severe impairment of well being.
Given that obesity treatment requires considerable efforts and resources, we suggest a pragmatic approach to managing patients at the different stages of obesity:
For STAGE O: Identification of factors contributing to increased body weight. Counseling to prevent further weight gain through lifestyle measures including healthy eating and increased physical activity.
For STAGE 1: Investigation for other (non-weight related) contributors to risk factors. More intense lifestyle interventions, including diet and exercise to prevent further weight gain. Monitoring of risk factors and health status.
For STAGE 2: Initiation of obesity treatments including considerations of all behavioral, pharmacological and surgical treatment options. Close monitoring and management of comorbidities as indicated.
For STAGE 3: More intensive obesity treatment including consideration of all behavioral, pharmacological and surgical treatment options. Aggressive management of comorbidities as indicated.
For STAGE 4: Aggressive obesity management as deemed feasible. Palliative measures including pain management, occupational therapy and psychosocial support.
As outlined in my earlier post – this Staging System is to be used together with the conventional BMI cutoffs.
In a world of limited healthcare resources and an already huge burden of people with obesity, we believe that the “biggest bang for the buck” will come from treating individuals with Stage 2 or 3 obesity. This of course should not divert from the efforts at prevention and halting the progression of obesity in individuals with Stages 0 and 1.
Judging by the early media response to this article, I assume that this paper will initiate a broad discussion not only on how to refine this system but also on whether or not this system will in fact be found effective in better managing patients struggling with excess weight (we are already piloting this system in our Edmonton clinic).
Appreciate all questions, comments and suggestions.