Arya M. Sharma, MD

Earlier this week, the Manitoba Centre for Health Policy (MCHP) released a report on Adult Obesity in Manitoba: Prevalence, Associations, and Outcomes.

The document (and especially the summary) makes an interesting read as it describes the rather complex nature of the epidemic and its impact on Manitobans.

While the analysis of about 35,000 Manitoba adults over the age of 18 who took part in one of three surveys between 1989 and 2008, documents the high prevalence of obesity and the fact that many health conditions are indeed more common in people with higher BMI’s, it also shows that these findings do not readily translate into higher healthcare costs till about a BMI of 33.

Thus, as the report summarizes:

“The Obese group almost always used more healthcare services than the other groups. However, the differences were small and often did not come into play until the very highest BMIs….people in the Obese group visited doctors more often than others. However, they only visited about 15% more overall. As well, the rise in visits only occurred from a BMI of 35 for men and 32 for women.
Likewise, costs of prescription drugs went up quite slowly until very high BMIs were reached. Hospitalizations were higher for those in the Obese group, but only for BMIs at or above 33. Home care use did not differ much either.”

This finding is actually not that surprising or unexpected.

Regular readers will by now be quite familiar with the Edmonton Obesity Staging System (EOSS), which was developed exactly because BMI is such an inadequate measure of risk or health.

Thus, I am confident that applying EOSS to this analysis would produce substantially different results than simply looking at BMI.

Thus, for e.g. our recently published analyses show that about 50% of people in the overweight category actually rank as EOSS 2/3. These individuals would considerably amplify the costs of people within the BMI 25-30 range - probably to the same level as EOSS 2/3 in the Obesity categories, while the obese EOSS 0/1 folks (of which there are about 20% in the BMI 30-35 class) would have costs very much like those of the EOSS 0/1 overweight people.

Such overlap in EOSS stages across BMI levels would readily mask any relationship between BMI and healthcare costs till rather extreme levels of BMI, where very few people will remain with EOSS 0/1 and the costs of being EOSS 2/3/4 would be substantially higher.

Thus, the ability of BMI to explore and interpret the cost of ‘obesity’ is limited, as it misses all of the ‘excess-weight-related’ health problems in the Overweight group while diluting the health care costs in the Obese group due to a substantial number of obese EOSS 0/1 people found in the moderately Obese group.

Thus, although I agree with the findings that higher health-care costs are only identifiable in individuals with moderate to severe obesity, I also sense that this report substantially underestimates the true cost of ‘excess-weight-related’ health problems.

The report also looked at ‘risk factors’ for obesity - a topic that I will comment on in tomorrow’s post.

A Summary of the Report is available here

The Complete Report is available here

AMS
Edmonton, Alberta

Regular readers are by now quite familiar with the Edmonton Obesity Staging System (EOSS), which describes how ’sick’ rather than just how ‘big’ patients are.

In a paper just published in OBESITY SURGERY, we discuss how EOSS could be applied to better determine indications for bariatric surgery.

As we point out:

“…health technology assessments specify that bariatric surgery is cost-effective in patients with diabetes (EOSS stage 2). In contrast, the cost-effectiveness of bariatric surgery in patients without comorbidities (EOSS <2) is far less clear. Thus, it is likely that a formal health economics analysis based on the EOSS criteria will support the cost-effectiveness of bariatric surgery for EOSS 2/3 patients, with minimal (if any) cost-effectiveness (even in the long-term) in EOSS 0/1 individuals.”

We also note that:

“It may be argued that bariatric surgery prioritized to EOSS scores 2 and 3, who have increased severity of obesity-related comorbidities, rather than scores 0/1 may miss the opportunity to apply bariatric surgery as a preventative measure. However, in a public-funded health-care system, with limited access and resources, it is prudent to prioritize these resources to those in greatest need. In addition, there is little known about the natural history of obesity, and thus, it remains challenging to predict who will indeed progress to higher EOSS stages and who will remain stable.”

Clearly, our recent publications on EOSS have made it evident that BMI criteria alone are neither a good measure of health nor an adequate predictor of mortality.

Whatever the utility of BMI in population surveys may be, it’s use in clinical decision making is clearly limited - this will need to be reflected in future guidelines and practice recommendations.

AMS
Edmonton, Alberta

Gill RS, Karmali S, & Sharma AM (2011). The Potential Role of the Edmonton Obesity Staging System in Determining Indications for Bariatric Surgery. Obesity surgery PMID: 22002510

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

EDMONTON OBESITY STAGING SYSTEM

Although higher BMI levels are generally associated with greater mental, medical and functional problems, anthropometric measures alone are not a good reflection of the severity or extent of obesity-related comorbidities. Sharma and Kushner have recently suggested a clinical staging system to complement the BMI when describing the severity of obesity.

The Edmonton Obesity Staging System consists of the following five stages:

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 or impairment of well-being.

Stage 1: Patient has one or more obesity-related sub-clinical risk factors (e.g., elevated blood pressure, 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 one or more established obesity-related chronic diseases requiring medical treatment (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate functional limitations and/or moderate impairment of well-being.

Stage 3: Patient has clinically significant end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/or significant impairment of well-being.

Stage 4: Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations and/or severe impairment of well-being

The Edmonton Obesity Staging System is used together with BMI class as follows:

Case 1: A 24-year-old physically active female with a BMI of 32 kg/m2 with no demonstrable risk factors, functional limitations or self-esteem issues would have Class I, Stage 0 Obesity. In this patient the focus would be on prevention of further weight gain. Health benefits of more aggressive obesity treatment would likely be marginal.

Case 2: A 32-year-old male with a BMI of 36 kg/m2 who also has essential hypertension and obstructive sleep apnea would have Class II, Stage 2 Obesity. This person would have a clear indication for obesity treatment.

Case 3: A 45-year-old female with BMI of 54 kg/m2 who is in a wheelchair because of disabling arthritis and severe hypopnea would have Class III, Stage 4 Obesity. This patient will either require aggressive obesity treatment or be deemed palliative.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Yesterday, at the 29th Scientific Meeting of The Obesity Society, I spoke at a session on the history of obesity, hosted by George Bray and David Haslam, author of Fat, Gluttony and Sloth: Obesity in Literature, Art, and Medicine.

In my talk, I discussed the history of the Quetelet Index, later named the Body Mass Index by Ancel Keys; I spoke about its limitations in clinical practice and presented the Edmonton Obesity Staging System (EOSS) and our latest data showing that this staging system is a far better predictor of mortality than BMI (or waist circumference).

Although it is far too early to know whether or not EOSS (or a variation thereof) will eventually be more widely used in clinical practice, research and policy, I could not but sense that the audience fully appreciated the need for a clinical obesity staging system, which characterizes how ’sick’ rather than simply how ‘big’ patients are. Clearly, such a system is but a natural evolution in our thinking about obesity, especially its treatment.

Click here to download a short powerpoint presentation on the Edmonton Obesity Staging System.

AMS
Orlando, FL

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

CLINICAL ASSESSMENT

Obesity affects virtually every organ system, and a comprehensive history and physical exam is an essential first step to treatment. Chapter 1 outlined the prerequisites for office set-up, for putting obese patients at ease during the clinical encounter. Body size can make physical examination difficult, reducing the clinical sensitivity of palpation, percussion, and auscultation. Severely obese patients may take longer to undress and may need assistance putting their clothes and shoes back on. Excessive sweating and limited physical hygiene due to difficulty in reaching all parts of the body may pose further embarrassment. Simple requests such as providing a urine or stool sample may be physically impossible for patients who cannot access their private parts. Clinical assessment includes determining the patient’s degree of obesity, which affects their risk of co-morbidities. A number of tools can be used in combination to avoid some of the shortcomings each method has on its own.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.