Thursday, August 25, 2011

Public Health Implication of the Edmonton Obesity Staging System

Continuing our discussion on the implications of the recent publication of our two studies showing that the Edmonton Obesity Staging System (EOSS), which actually measures how ‘sick’ patients are rather than just how ‘big’ patients are, is a better predictor of mortality than BMI, I’d like to briefly discuss a potential implications for public health messaging around obesity and health promotion.

In contrast to what some media commentators have chosen to imply (‘It is now OK to be fat’), EOSS actually takes a very differentiated view of the complexity of the relationship between excess weight and illness.

In fact, one key learning for public health messaging from our EOSS papers, would clearly be to re-evaluate the entire notion of a ‘healthy weight’, an outdated and misleading concept that harks back to the rather simplistic idea of ‘ideal’ weight.

Indeed, we previously criticized the notion of ‘ideal’ weight in an article published in 2009 in SOARD, in which we lamented the use of ‘Excess Weight Loss’ in the bariatric surgical literature.

As we noted in that article:

…“ideal weight” is synonymous with the term “desirable weight,” first introduced in 1943 by the Metropolitan Life Insurance Company (MLIC) in their standard height-weight tables for men and women. These tables were determined from actuarial data indicating the lowest mortality risk related to a range of weights for a given height in the studied population. Recognizing that the relationship between mortality and body weight is anything but simple, the MLIC life tables also introduced the concept of frame size, a concept that was hard to understand and implement and was therefore largely ignored. In fact, the current common use of “ideal weight” generally refers to the medium frame category, regardless of the patient’s actual size or form. Nevertheless, it is important to recognize that for a 170 cm (5’ 7”) woman, depending on her frame size, the MLIC “ideal weight” can range from 56 kg for a small frame to 74 kg for a large frame, or a difference of 18 kg. This translates into a body mass index (BMI) range of 19.3–25.6 kg/m2, or more than 6 BMI points.”

Thus, not only was this notion of ‘ideal’ weight based on an unrepresentative actuarial sample but there was actually a weight range of about 18 kg (or about 40 lbs) over which a person’s weight for the same height could be considered ‘ideal’.

Our recent EOSS data shows that for some people (albeit a minority at higher BMI levels), this range of ‘ideal’ weight based on mortality can indeed be even larger.

Thus, recognizing that weight (or BMI) is indeed such a crude (some would say irrelevant) measure of ‘health’, the entire concept of ‘healthy weights’ may need to be abandoned in favour of a more differentiated look at the rather complex relationship between health and weight.

At a minimum, public messaging around obesity, may need to make it very clear that ‘health’ can be achieved and maintained across a wide range of weights and that it is probably far more important to focus on health behaviours and other indicators of health than to jump to conclusions about someone’s health based solely on their weight.

Obviously, I fully appreciate that public health messages need to be kept simple but there are certainly arguments to be made that, given the rather loose relationship between health and weight, continuing to promote the notion of ‘healthy weights’ may do more harm than good, as such messaging would simply continue to promote obesity related stereotypes and can potentially set people off on paths of unhealthy weight loss in the firm belief that losing weight is equivalent to improving health.

On the other hand, none of this should distract from the fact that we do have an obesity epidemic and that the vast majority of people with ‘excess’ weight do indeed have relevant comordibities that put them in higher EOSS categories – for these individuals, improving access to evidence-based preventive and treatment resources must be a priority of any healthcare system.

I can certainly see how dealing with this rather complex problem in public health messages and policies will likely lead to a most interesting discussion in the months to come.

AMS
Edmonton, Alberta

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5 Responses to “Public Health Implication of the Edmonton Obesity Staging System”

  1. Mark says:

    Dr. Sharma,

    Your blogs have been incredible lately. And with all this great discussion, I’ve had a question that keeps burning in my mind that perhaps you can answer.

    If health is only loosely associated with weight and we can agree that the focus needs to be on health related behaviours, what differentiates bariatric care from health care that should be provided to those not classified as obese or overweight?

    Should we not just emphasize health behaviours in ALL patients regardless of size?

    And if this is the case, should patients whose comorbidities can be improved by weight loss be the only ones referred for weight management?

  2. DebraSY says:

    “At a minimum, public messaging around obesity, may need to make it very clear that ‘health’ can be achieved and maintained across a wide range of weights and that it is probably far more important to focus on healthy behaviours and other indicators of health than to jump to conclusions about someone’s health based solely on their weight.”

    Amen! And, yes, public messages must be simple, as you go on to say, but adjective-based messages, such as “healthy weight” or “ideal weight” are far from simple since adjectives are unclear, subjective and invite interpretation (followed by disagreement). Whenever there is this much lack of clarity, then the entity with the largest advertising budget (in this case the diet industry and the prurient TV reality show biz) will win the popular sentiment and define terms to their own benefit.

    I think that public policy needs to remain weight neutral. It is enough for everyday people to endeavor to maintain a constant weight. (Most people gain a pound or two every year.) The government should assist the challenging process of health promotion and weight maintenance both with clear messaging and with its farm subsidy policy. Weight change (down or up) should ONLY be attempted in consultation with a doctor.

    Now, Dr. Sharma, more power to you as you educate your colleagues so that they do no harm. Many of them, sadly, are woefully behind in this area and have succumbed to popular weight-loss mythology.

  3. Anonymous 8:06am to DeeLeigh says:

    Nix to the farm subsidies. They are a boondoggle. More likely the agribusinesses or producers’ organizations will try to influence the gov’t to promote what they want to sell. Look at the diary industry who work to increase the quantity and frequency of consumption of mostly high fat products. We do not need a HEALTH policy influenced by food producers, processors, or sellers.
    The government should also remain food neutral. The Canada food guide was started to solve the problems of deficiency diseases. Those are not a significant problem in Canada now. The main eating problem in Canada is eating too many calories and the food guide says absolutely nothing about that. The Canada food guide, in ignoring the main food problem, is now worse than useless, so it would be best to disband it.

    If weight alone is not a health problem there is no need for public messaging about weight at all.

    All the money should be directed to the treatment of “co-morbidities” – no public messaging is needed for that, people are banging on doors trying to get to see their doctors – or to get a doctor at all. In the US it is said a large part of the money spent on health care goes to the insurance system, not actual health care – which apparently they feel is worth it. In Canada there is a danger of a huge part of our money being spent on committees and agencies and conferences and advertising with very little result except that the people involved talk to each other. We need an “evidence – based” approach that regards any expenditure as a part of our health care costs. The cost of any activity supposedly promoting heath has to be compared with the value of that money put directly into doctor, nurses, supporting staff and infrastructure for care delivered right to the patient. Only a few conditions would warrant public messaging, for example a SARS type situation.

    And if weight is not a health problem, then a doctor’s visit for weight loss/gain/maintenance in the absence of any co-mordidity should be not covered by public health insurance. It is not a health concern, it’s a cosmetic concern, and the person should pay for that out of his or her own pocket (as I have paid to have a doctor remove a large mole from my face for purely cosmetic reasons).

  4. DeeLeigh says:

    Well, if you’re going to delete my post after approving it, you should probably nix Anonymous’s reply as well.

  5. 30 min workout system says:

    Good article. I definitely love this site. Thanks!

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