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.
AMS
Edmonton, Alberta
In The News
February 11th, 2009 at 7:15 am
Congratulations on the article publication. This staging approach seems like a very good way to fill the gap between BMI diagnoses and treatment decisions. Thank you for taking a common sense approach to grading obesity-related health issues.
February 11th, 2009 at 7:19 am
Great job Arya!
February 11th, 2009 at 7:45 am
Arya,
Congratulations on your article. It seems useful to have a staging system of intervention since not all patients with obesity suffer equal morbidity. I will send it to our clinicians at Emory Bariatrics and let you know any feedback I get. I also look forward to the results of your pilot study.
February 11th, 2009 at 8:50 am
This staging is a very practical approach to a very complex clinical picture.
This helps define the degree of efforts a physician should expend in treating different stages and clinical presentations of obesity.
February 11th, 2009 at 9:01 pm
I liked your article very much. If indeed the cutoffs aren’t completely inclusive or exclusive it helps a lot to improve the clinical judgment and comprehensive mangament of people with obesity and it will surely motivate further understanding of the conditions associated with it. I have seen a couple of patients with BMI >40 with no complaints (not even knee osteoarthritis) except for their worry ness to be sick and a lot others with overweight who suffer from conditions most probably promoted by body fat, so I think the article is a step forward in clinical management of obesity. Congratulations!
February 11th, 2009 at 11:27 pm
Arya, you are already aware that I am your biggest fan, and our clinic prides itself in following the guidelines that you establish. We have been using the EOSS for months now, prior to the publication. The majority of the 2000 pts at the Wharton Medical Clinic have been assigned with an EOSS value. I ensure that my consult notes indicate that the EOSS is credited to Sharma and Kushner, and I include a copy of the full table. I believe this is a great educational tool for the physicians who refer patients to our clinic. It is now part of our searchable parameters. We would love to collaborate with others as they use the EOSS to determine the usefulness for bariatric physicians and for the family doctors who receive our consult notes. Bottom-line - thanks Arya and Robert for this great addition to our field.
February 12th, 2009 at 1:13 am
I discussed your article (I referred to the abstract and this post, as well as the article on Canada.com) on my blog — which reaches lay fat people.
Here’s the link:
http://www.google.com/reader/shared/user/12383239744273972341/label/Notes%20from%20the%20Fatosphere
I hope that this system does lead to better treatment of the health of people with high BMIs.
February 12th, 2009 at 8:29 am
[...] Read posting on http://www.drsharma.com (allows comments) [...]
February 12th, 2009 at 11:04 am
[...] Dr. Sharma’s blog [...]
February 18th, 2009 at 8:11 am
[...] Edmonton WeightWise (WW) Community Network) or OPTIFAST (often used in WW as a rescue strategy in Stage 4 patients and also provided by a WW Community Network Partner) may be effective in some individuals [...]
March 2nd, 2009 at 6:09 am
[...] readers of these pages, may recall that we recently proposed a Clinical Staging System of Obesity, where the recommendation for Stages 0 and 1 obesity is NOT weight loss, but rather just prevention [...]
March 2nd, 2009 at 3:49 pm
[...] Posted by attrice on March 2, 2009 Dr. Sharma, a Canadian physician who specializes in and blogs about obesity, weight and health (and who I keep meaning to put on my blog roll), felt that BMI and waist circumference were not very helpful parameters when dealing with the realities of individual patients. So he and another doctor put on their thinking caps and came up with what they’re calling the Edmonton Obesity Staging System. [...]
March 3rd, 2009 at 11:13 am
[...] See the Edmonton Obesity Staging framework here and go here for the details about the stages, clinical parameters, and specific treatment recommendation…. [...]
March 19th, 2009 at 6:04 am
[...] we also know that BMI is not a perfect measure of health. This is exactly why we introduced the Edmonton Obesity Staging System, where we stage obesity based on the actual presence of risk factors or comorbidities rather than [...]
March 20th, 2009 at 5:37 pm
[...] good message to get out in the press. But I also doubt that Dr. Sharma’s view of “benign/stage 0 obesity“ includes someone my size. After all, I weigh 400lbs, I have sleep apnea (same as my thin [...]
May 15th, 2009 at 5:58 am
[...] Today I’ll make it real short: many of you may recall my recent paper, co-authored by Robert Kushner, President of the Obesity Society and Professor of Medicine at Northwestern University, on the Edmonton Obesity Staging system. [...]
May 16th, 2009 at 8:56 pm
I just read the article in MacLean’s and I was thrilled that a shift in thinking is finally occurring. I think the staging system is fantastic, and if widely used, will help patients immensely. I’ve had some pretty ridiculous things said to me in a doctor’s office based on weight alone, without taking into account my lifestyle and other factors. It would be great, from a patient perspective, to be able to be treated much more individually than the BMI allows. Thank you so much!
July 6th, 2009 at 4:01 pm
That still does not answer the question as to whether weight loss benefits people with disease risk factors. Yes, it “fixes” the surrogate measures (A1C, lower cholesterol, etc.), but there is still no proof that weight loss benefits an obese person in terms of a reduction in the absolute risk of severe outcomes in morbidity and mortality.
There is an article in the Journal of Nephrology from last year written by Dr. Nortin Hadler, MD that offers convincing data to show that the current treatments for problems related to type 2 diabetes are largely ineffective in doing anything other than just treating the numbers.
Also, this from a great health blog: http://junkfoodscience.blogspot.com/2009/06/figure-flaw-paradox-does-it-really.html
January 6th, 2010 at 1:50 pm
This makes so much sense. If only the AMA would pick on properly identifying obesity. It is extremely progressive and should be analyzed this way!