Arya M. Sharma, MD

I was recently asked by the editor of the journal Evidence Based Medicine to provide a commentary on an article by Post and colleagues examine the influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity published in the Archives of Internal Medicine.

The participants (NHANES 2005-2008) were asked whether they had been told by their physician or another health professional that they were overweight. The main outcome measure was the proportion of participants who considered themselves as ‘not overweight’ versus ‘overweight’ in two different BMI classifi cations: overweight (BMI 25.0) and obese (BMI 30.0). Secondary measures included participant perceptions of desired weight and weight loss attempts in the last 12 months.

Outcomes were controlled for age, sex, race, poverty-to-income ratio, marital status, education, whether the patient has a routine source of healthcare and the number of physician visits in the last 12 months.

In participants with BMIs of 25 or greater and 30 or greater,45.2% and 66.4% reported having been told by their physician that they were overweight or obese, respectively.

Participants who reported having been told they were overweight were more likely to identify themselves as overweight (94.0% vs 63.1%) or obese (96.7% vs 81.4%). Similarly, participants who reported having been told they were overweight were more likely to desire to lose weight (96.1% vs 73.7%) and report a weight-loss attempt (64.7% vs 39.0%).

From these finding the researchers concluded:

“Among patients who were overweight or obese, patient reports of being told by a physician that they were overweight were associated with more realistic perceptions of the patients’ own weight, desire to lose weight, and recent attempts to lose weight.”

Here are excerpts from the commentary that I had to offer:

Given the cross-sectional and retrospective nature of this study, it may

“be fairer to conclude from this study that patients who recall discussing their excess weight with their physicians are also more likely to consider themselves overweight and obese as well as more likely to recall a recent weight loss attempt.

“….even if identifying and raising the issue of excess weight may motivate more patients to lose weight, it is unclear that this would indeed result in a long-term benefit to patients…..one may argue that simply raising the issue of excess weight and getting patients to try to lose weight on their own may have little effect on long-term health outcomes unless this weight loss is achieved by healthy means and is sustainable in the long term. Evidence suggesting that increased numbers of weight loss attempts are prognostic of future weight gain should also give cause to caution in equating a history of weight loss attempts with better health.”

“…although it is safe to conclude that fewer than half of overweight and fewer than two-thirds of
obese participants have been told by their physicians that they were overweight, it remains unclear whether increasing these numbers to the levels reported in those individuals who have been told will actually result in improved health behaviour and outcomes for the individuals concerned.”

I’d certainly want to hear from my readers on this - has being having your weight pointed out by your doctor ever been helpful? Do my colleagues think that pointing out excess weight to their patients elicits a positive and healthy response? if not, why?

AMS
Edmonton, Alberta

Sharma AM (2011). Physicians’ calling patients on excess weight may provide reality check and increase desire to lose weight in overweight and obese individuals. Evidence-based medicine PMID: 21856640

Post RE, Mainous AG 3rd, Gregorie SH, Knoll ME, Diaz VA, & Saxena SK (2011). The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Archives of internal medicine, 171 (4), 316-21 PMID: 21357807

Over the last several days I have been examining various aspects and implications of our recent publications showing that the Edmonton Obesity Staging System (EOSS) does a far better job of predicting mortality than does BMI (in fact BMI does almost nothing in this regard).

Not only does EOSS make intuitive sense to clinicians and most patients (especially the ones who are at EOSS 0) it is also a better way to individualize patient management strategies.

But, despite these two publications in three independent samples that included over 20,000 participants, many important questions remain to be addressed:

it is not clear whether all comorbidities should receive the same weight for defining the EOSS stage - for e.g. should chest pain due to reflux disease count the same as chest pain due to ischemic heart disease (probably not)?

What is the natural history of EOSS stage progression? Or in other words, how long does it take for patients to move from Stage 0 to Stage 1 or from Stage 2 to Stage 3? Are there really patients, who never progress? Are there predictors of progression? If yes, can this progression be delayed or prevented?

What does it take to reverse Stages and does reversing the obesity Stage improve prognosis (it probably does)?

How do cost-effectiveness and risk-benefit ratios of obesity treatment for patients look at different EOSS stages? I am guessing that both increase at higher stages, but is this really the case?

Can we develop a simplified version of EOSS (EOSS-lite?) that only counts certain comorbidities or only acknowledges certain dimensions of quality of life?

Is EOSS a concept that health professionals, decision makers, and funders are ready to adopt and will it improve practice and outcomes?

These are all questions that future research will need to address, some of this work is already underway, but I’d be happy to hear from potential collaborators or people wanting to do some of this research on their own.

If nothing else, I at least hope that the EOSS discussion has opened a whole new way of thinking about clinical assessment and definition of obesity and will find its way into clinical care pathways and management guidelines.

From everything I hear, this is already beginning to happen.

AMS
Edmonton, Alberta

Padwal RS, Pajewski NM, Allison DB, & Sharma AM (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne PMID: 21844111

Kuk JL, Ardern CI, Church TS, Sharma AM, Padwal R, Sui X, & Blair SN (2011). Edmonton Obesity Staging System: association with weight history and mortality risk. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme PMID: 21838602

Amongst all the enthusiastic accolades that welcomed the publication of the two recent papers showing that the Edmonton Obesity Staging System (EOSS) is superior to BMI in predicting mortality risk, there were some commentators (including readers of these pages), who apparently misinterpreted these findings as ‘a license to be fat’ or even ‘as sending a devastating public health message that fat can be healthy’.

While the lay media and lay readers may be forgiven for this simplistic and cursory interpretation of our findings, more sophisticated readers should actually have noted that nowhere in these papers (or in the original proposal for EOSS) do we ever equate EOSS 0/1 (low risk) with doing nothing.

In fact, we were very careful in pointing out that even patients presenting with EOSS 0/1 should be investigated for underlying drivers of weight gain and should be counselled on prevention of further weight gain (weight maintenance) and, insofar there is indeed any additional room for improvement, to eat healthily and get as much activity as they can enjoy.

The caveat regarding ‘additional room’ was put in to imply that, yes, people in lower EOSS categories already appear to be eating quite healthy and certainly are more physically fit than their higher-risk EOSS counterparts (meaning - they may already be doing the best they can).

To me, investigating someone for the causes of excess weight, counselling on weight maintenance, and scheduling repeat consults (say at 12-18 months) is not ‘doing nothing’. It is also by no means ‘a license to be fat’ (as if being fat - per se is a bad thing).

In fact, the whole point of EOSS is to better identify and focus treatment on high-risk individuals while pretty much leaving lower-risk EOSS folks alone (albeit with minimal investigation and intervention).

But of course, this notion is unlikely to appease the ‘weight-loss-at-all-cost’ enthusiasts, who firmly believe that there is something inherently ‘unhealthy’ about extra fat (when clearly our studies show that there isn’t).

These ‘weight-loss-enthusiasts’ will also make the ‘prevention’ argument, which of course is based on nothing, given that there are indeed no studies showing that obese people who are currently healthy (or which subset of these) will actually progress to developing relevant morbidity, IF THEY CONTINUE TO MAINTAIN THEIR CURRENT WEIGHT AND HEALTHY LIFESTYLES!

As it takes months if not years or even decades to progress from one EOSS stage to the next, and as most health problems in EOSS 1 and 2 (by definition) are reversible, there is really no argument to pre-empt these problems by recommending weight loss to people, who really have no weight problem.

Indeed, if the first rule of medical practice is ‘do no harm’, I would be the first to point out that recommending weight loss to someone, who is essentially healthy, actually does have the potential to do harm.

Firstly, this person could go out and begin engaging in unhealthy weight loss practices just to get those supposedly ‘extra’ pounds off - this practice alone could pose a health risk.

Secondly, losing some weight only to put it right back on (as do 95% of people who try to lose weight) may well have negative physical and emotional consequences (not to mention the negative impact on their wallets).

Thirdly, having engaged in ‘unsuccessful’ weight loss may make this person less motivated and perhaps even less likely to succeed in losing weight, when, at a later time, this may indeed be indicated - crying ‘wolf’ now may simply lead to the real wolf being ignored later.

But here is a final argument that could perhaps appease the ‘weight-loss-at-any-cost’ enthusiasts - we are (sadly perhaps) only talking about a minority of overweight and obese people, to whom this ‘low-risk’ status actually applies.

Thus, in the overweight category, only 15% of the individuals were EOSS 1, a proportion that decreased to only 8-5% in higher BMI classes.

Thus, the supposed ‘licence’ would in any case only apply to 1 in 6 overweight folks or even only 1 in 15-20 folks with a BMI over 30 - the vast majority would not be in this supposed ‘wait and see’ category.

Indeed, amongst individuals with Class II or III obesity, almost 80% of individuals were classified as EOSS 2/3 - this is the group that is very likely to benefit from obesity treatments.

As I’ve said before, EOSS adds important shades of grey to what many consider to be black or white - either you are at a ‘healthy weight’ (whatever that is) or you need to lose weight - whether or not you are actually healthy at your current weight does not appear to enter into their reasoning.

Of course, when there is money to be made in weight loss, and when most of your clients happen to be EOSS 0, our studies suggest that you should perhaps consider changing your business model (or at least have your clients sign a consent form stating that losing weight may not be in their best interest).

But if you are a health professional or decision maker wondering about just how to dedicate your limited resources to those obese patients most likely to benefit, first addressing the needs of those presenting with higher EOSS stages seems a perfectly rational and reasonable argument.

Only if you still believe that health can be measured simply by stepping on a scale, are you likely to continue thinking that EOSS is a disservice to medical care and dangerous to the public.

For the rest of us, hopefully, EOSS will prove a viable strategy to deliver evidence-based health care to where it is needed the most.

AMS
Ottawa, Ontario

Padwal RS, Pajewski NM, Allison DB, & Sharma AM (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne PMID: 21844111

Kuk JL, Ardern CI, Church TS, Sharma AM, Padwal R, Sui X, & Blair SN (2011). Edmonton Obesity Staging System: association with weight history and mortality risk. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme PMID: 21838602

As readers of these pages are well aware, there is currently only one prescription drug (orlistat) for the long-term management of obesity and recent applications for new anti-obesity drugs have run into considerable obstacles with licensing agencies, not least the US Food and Drug Administration.

Thus, despite meeting criteria for efficacy, recent applications for new anti-obesity drugs were rejected due to safety concerns, the argument being that the expected widespread use of these drugs warrants higher standards of safety than for drugs in other therapeutic areas.

This may well be true, if anti-obesity drugs are indeed to be made freely available (even on prescription) and are to be used without careful consideration of the risk/benefit ratio.

As discussed previously in the context of bariatric surgery, the risk side of this equation is not limited to the ‘risk’ associated with treatment but must also include the ‘risk’ associated with not treating the condition.

As our recent papers on the Edmonton Obesity Staging System (EOSS) clearly show, the ‘risk’ associated with obesity varies considerably - from virtually no risk for patients with EOSS 0 to very significant and immediate risk for patients with EOSS 3.

So, while even the smallest treatment-related risk may be unacceptable for treating obesity in a patient with EOSS 0, a higher level of risk would be certainly be acceptable with higher EOSS stages - or in other words - the greater the risk of not treating, the greater the acceptable risk for a potentially beneficially treatment (which, for e.g., is why cancer warrants the considerable treatment risks of chemotherapy).

Of course, this would mean that rather than having to prove the safety and efficacy of anti-obesity drugs in anyone with a BMI over 30, it may be enough to show that these drugs are effective and safe enough to warrant their use in people with higher EOSS stages (2/3) - the greater the risk of the target population, the greater the acceptable risk of treatment.

This should not be difficult. We know that many of the conditions that patients with EOSS 2/3 present with can be ameliorated even with rather modest weight loss. For these patients, the 5-10% sustainable reductions in body weight that can be achieved with anti-obesity drugs, can have very significant health benefits, which would easily outweigh and justify a reasonable risk of adverse effects - a risk that may be unacceptable in patients presenting with EOSS 0/1 obesity.

This, of course means rewriting some of the approval criteria and guidelines for anti-obesity drugs, but also requires redesigning pharmacological trials to focus on the high-risk EOSS 2/3 patients rather than on the low-risk EOSS 0/1 patients.

I certainly look forward to following how this discussion evolves and wether or not we can indeed find a way out of the current impasse of anti-obesity drug development and approval.

AMS
Toronto, Ontario

Padwal RS, Pajewski NM, Allison DB, & Sharma AM (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne PMID: 21844111

Kuk JL, Ardern CI, Church TS, Sharma AM, Padwal R, Sui X, & Blair SN (2011). Edmonton Obesity Staging System: association with weight history and mortality risk. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme PMID: 21838602

One of the questions many readers and colleagues have asked, is whether or not the issue of ‘causality’ should matter in the the context of the Edmonton Obesity Staging System (EOSS).

In other words, should only conditions be counted that are ‘causally’ linked to obesity or is it enough that these conditional are merely more common in people with excess weight.

There are essentially two important but distinct aspects to this question that ultimately relate to how EOSS is to be used in clinical practice.

If the primary purpose of EOSS is to identify patients who would benefit from weight loss, then, yes, it matters whether or not the co-morbidities considered, are ‘causally’ related to obesity and can be reversed or ameliorated by reducing and sustaining a lower body weight.

However, if the primary purpose of EOSS is merely to identify obese patients, who are at high risk and need to be prioritized within the health care system in order to receive the appropriate care for their conditions (irrespective of whether or not this ‘care’ involves weight loss or just better management of their comorbidities), then the question of causality is really irrelevant.

Thus, in the first case, one would only count ‘comorbidities’ that are actually ‘causally’ related to excess weight - an example being sleep apnea. There is ample evidence that weight loss reduces symptoms of sleep apnea (while weight gain makes it worse) and so sleep apnea would count as an important comorbidity that can be addressed by obesity treatment.

In the second case, it does not actually matter if the comorbidity is in any way related to excess weight. All that really matters, is whether this comorbidity is present or not. An e.g. would be depression, which, while not caused by obesity and not likely to improve with weight loss (it may sometimes even get worse), may, when present, help identify obese patients, who do have a higher risk of premature death.

So while in the first example, EOSS would be used to decide who needs to lose weight, in the second example, EOSS simple serves to identify obese people, who are at highest risk of complications and death.

Apart from the second scenario being the real reason that EOSS was developed, it is also a far more practical approach to using EOSS, because for many comorbidities it may be impossible to answer the ‘chicken or egg’ question or even determine if these are simply two different chickens.

In clinical medicine this phenomenon is referred to as ‘phenocopy’, a term used to describe a case where two distinct and unrelated conditions, present clinically with the same symptoms or ‘phenotype’.

In obesity, this is particularly common, because, while many symptoms may be ‘causally’ related to obesity, these same symptoms may just happen to present in an obese individual but have nothing to do with that patient’s excess weight.

For EOSS, this question would not really matter - whether the knee pain is from an accident or from carrying around the excess weight makes no difference - the only thing that matters is that this is a patient with excess weight AND knee pain and therefore, this patient is an obese patient, who is at higher risk for mortality than an obese patient without knee pain.

Remember, bariatric care, as I define it, is not about losing weight but rather about medical care for the bariatric patient. As resources are limited, all I want EOSS to tell me is, who to see first.

Of course there are ‘normal-weight’ people with knee pain, but they are not my problem. There are also ‘normal-weight’ people with high blood pressure, sleep apnea, diabetes and depression - again, they are not my problem.

As someone, who works in an obesity clinic, my job is to assess obese patients and help them the best I can, whether their treatment requires weight loss or not. If EOSS can help me decide, who to see most urgently, then EOSS has done its job.

Of course, further research is needed to determine whether EOSS actually works well in clinical practice (e.g. outside of a speciality centre) and we may perhaps need to simplify and clarify the criteria. But the principle stands: it is simply not enough to look at BMI to decide who needs (urgent) medical attention and who does not.

AMS
Edmonton, Alberta