It would hardly come as a surprise to regular readers that I would be delighted to see the Edmonton Obesity Staging System featured quite prominently in the article on obesity management by Dietz and colleagues in the 2015 Lancet series on obesity.
Here is what the article has to say about EOSS:
“The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1). EOSS provides a practical method to address the treatment paradigm. In principle, EOSS stages 0 and 1 should be managed in a community and primary care setting. Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m²) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs. These findings suggest that greater priority should be accorded to EOSS stages 3 and 4, resulting in greater focus on pharmacological and surgical management delivered in specialist centres.”
These recommendations are not surprising, as EOSS was specifically designed to provide a much better representation of how “sick” a patient is rather than just how “big” she is.
This is why EOSS has now found its way not just into the 5As of Obesity Management framework of the Canadian Obesity Network but also into the treatment algorithm of the American Society of Bariatric Physicians.
To download a slide presentation on how EOSS works click here.
The title of this post may sound like a “no-brainer”, but the research literature on the long-term health benefits of weight loss from longitudinal intervention studies in people with severe obesity is much thinner than most people would expect.
Thus, a new study from our group, that looks at the relationship between changes in body weight and changes in health status over two years in patients with severe obesity enrolled in the Alberta Population-based Prospective Evaluation of the Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, published in OBESITY, may well be of considerable interest.
As described previously, APPLES is a 500-patient cohort study in which consecutive, consenting adults with BMI levels > 35 kg/m2 were recruited from the Edmonton Adult Bariatric Specialty Clinic. The 500 patients enrolled were between 18 and 60 years old and were either wait-listed (n=150), beginning intensive medical treatment (n=200) or had just been approved for bariatric surgery (n=150). Complete follow-up data at 24 months was available for over 80% of participants.
At study enrollment, the proportion of patients who reported >2 and >3 chronic conditions was 95.4% and 85.8%, respectively. The most common single chronic conditions at baseline were joint pain (72.2%), anxiety or depression (65.4%), hypertension (63.4%), dyslipidemia (60.4%), diabetes mellitus (44.6%), gastrointestinal reflux disease (35.4%), and sleep apnea (33.5%).
After 2 years, just over 50% of participants had maintained a weight loss > 5%, with a mean weight change for the entire cohort of about 13 kg.
Losing > 5% weight was associated with an almost 2-fold increased likelihood of reporting a reduction in multimorbidity at 2-year follow-up, whereby outcomes varied between treatment groups: in the surgery group, the top three chronic conditions that decreased in prevalence over follow-up were sleep apnea (43% at baseline vs. 25% at 2 years,), dyslipidemia (60% vs. 47%), and anxiety or depression (59% vs. 47%); in the medically treated group anxiety or depression (69% vs. 57%) and joint pain (77% vs. 67%); and none in the wait-listed group.
As expected, any reduction in multimorbidity was associated with a clinically important improvement in overall health status.
In summary, this paper not only documents the considerable multimorbidity associated with severe obesity, it also documents the clinically important improvement in health status associated even with a rather modest 5% weight loss over 2 years in these individuals.
Anyone interested in the issue of obesity and cardiovascular disease may want to get a copy of the latest edition of the Canadian Journal of Cardiology, which includes a number of review articles and opinion pieces on a wide range of issues related to obesity and cardiovascular disease.
Here is the table of contents:
Lim SP, Arasaratnam P, Chow BJ, Beanlands RS, Hessian RC: Obesity and the challenges of noninvasive imaging for the detection of coronary artery disease.
Garcia-Labbé D, Ruka E, Bertrand OF, Voisine P, Costerousse O, Poirier P. Obesity and Coronary Artery Disease: Evaluation and Treatment.
Lovren F, Teoh H, Verma S. Obesity and Atherosclerosis: Mechanistic Insights.
Sankaralingam S, Kim RB, Padwal RS. The Impact of Obesity on the Pharmacology of Medications Used for Cardiovascular Risk Factor Control.
Piché MÈ, Auclair A, Harvey J, Marceau S, Poirier P. How to Choose and Use Bariatric Surgery in 2015.
Poirier P, McCrindle BW, Leiter LA. Obesity-it must not remain the neglected risk factor in cardiology.
Lang JJ, McNeil J, Tremblay MS, Saunders TJ. Sit less, stand more: A randomized point-of-decision prompt intervention to reduce sedentary time.
Nevertheless, for those, who still harbour any remaining doubts, the study by Ulf Ekelund on behalf of the EPIC Investigators, recently published in the American Journal of Clinical Nutrition should drive this message home.
This analysis looks at the relationship between physical activity and all-cause mortality in 334,161 European men and women followed for about 12.4 y (corresponding to 4,154,915 person-years).
No matter how the researchers looked at the data, activity levels appeared a better predictor of mortality than BMI or waist circumference.
Thus the authors calculated that while avoiding all inactivity would theoretcally reduce all-cause mortality by 7.35%, trying to maintain a “normal weight” (or rather a BMI less than 30) would reduce mortality by only 3.66% (although avoiding obesity AND inactivity did have the greatest effect).
Despite the limitations of these type of cross-sectional analyses, which as a rule, tend to overestimate the potential benefits of an actual intervention, the message is clear – it appears that even small increases in physical activity in inactive individuals can have substantially greater benefits to health than obsessing about losing a few pounds.
This is indeed useful information, as we have long known that increasing physical activity in most cases does surprisingly little in terms of weight loss but rather a lot in terms of increasing health and fitness.
So do not despair if the hours your patients are putting in at the gym are not changing those numbers on the scale – the health benefits are still worth the effort.
This week, I am in Reykjavik on behalf of the Icelandic Medical Association to speak at their 2015 Annual Conference.
Despite its proverbial rugged outdoorsy lifestyle with ample time spent in natural hot spring spas and saunas (both of which I enjoyed yesterday, thanks to my excellent hosts), Iceland has a significant obesity problem of its own – reason enough for this problem to be taken seriously (I will be meeting with the Icelandic health minister and his staff to discuss this issue later this week).
There is indeed a small but active obesity research community in Iceland with growing experience in the management of this disease.
One important contribution, for e.g. is the recent paper by Erla Bjornsdottir and colleagues from the University of Iceland, published in the Journal of Sleep Research, that examines the impact of two years of treatment vs. non treatment of moderate to severe obstructive sleep apnea (OSA) on quality of life in over 800 overweight or obese individuals newly diagnosed with this condition.
The comparator group consisted of 750 randomly selected Icelanders. The researchers also compared users and non-users of CPAP treatment within the individuals diagnosed with sleep apnea.
Overall, as one might expect, the quality of life (measured by the SF-12 questionnaire) of untreated individuals with OSA was markedly worse that of the general population, even when matched for age, body mass index, gender, smoking, diabetes, hypertension and cardiovascular disease.
Surprisingly, however, despite a positive trend towards improvement in physical quality of life from baseline to follow-up in users and the most obese individuals, there were no significant overall differences between full and non-users.
This is particularly surprising as I have often seen dramatic changes in the quality of life and general well-being in patients with OSA, who started on CPAP treatment in my practice (but I guess anecdotes are always tempered by averages).
Based on their findings, the researchers conclude that the co-morbidities of obstructive sleep apnea, such as obesity, insomnia and daytime sleepiness (often not fully controlled by CPAP), appear to have a substantial effect on life qualities and may need to be taken into account and addressed with additional interventions.
The message here, I believe, is that despite its effectiveness for better control of breathing, simply putting patients on CPAP and hoping for the best may not be quite enough to improve the substantially reduced quality of life associated with this disorder.