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Another Nail in BMI’s Coffin?

Regular readers will be well aware of the 5As of Obesity Management™ toolkit and patient resources developed by the Canadian Obesity Network.

In contrast to other existing guidelines, including the hopelessly irrelevant recent US Preventive Task Force Recommendations, the 5As of Obesity Management recommend the use of obesity stages (based on presence of risk factors, comorbidities and complications) rather than obesity class (based solely on BMI) to guide clinical decision making and interventions.

This, rather ‘bold’ recommendation is backed up by far stronger evidence than the use of BMI alone, not least through studies that have applied the Edmonton Obesity Staging System (EOSS) to several large independent datasets including NHANES and the Cooper Study, involving 10s of 1000s of participants.

And the evidence to support obesity stages is growing stronger by the minute.

Thus, in a paper by Anthony Jerant and Peter Franks from the University of California Davis School of Medicine, published in the Journal of the American Board of Family Medicine (JABFM), little, if any, relationship was found between BMI and mortality.

Based on their analysis of a population-based observational study of data from 50,994 adults aged 18 to 90 years who responded to the 2000 to 2005 Medical Expenditures Panel Surveys, 6-year survival (not adjusted for diabetes or hypertension) was only moderately (HR 1.26) increased for those with severe obesity (BMI > 35).

After adjusting for diabetes and hypertension, severe obesity was no longer associated with mortality, and milder obesity (BMI 30-<35) was even associated with decreased mortality (adjusted hazard ratio, 0.81).

Not only does this paper represent another nail in BMI’s coffin, it also further validates the concept of using a staging system to classify obesity based on actual (measured) risk and the presence of comorbidities and/or complications.

While BMI (and perhaps waist circumference) may well be simple screening tools, decision on who and when to treat should be based on obesity stage and not BMI.

Quebec City, Quebec

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  1. I certainly agree that
    “who and when to treat should be based on obesity stage and not BMI.”

    What about people who want to lose weight just to have a better quality of life?
    Like me. BMI 38, and according to my doctor, healthy.

    I don’t want to use precious health care resources paid for by taxpayers to help me lose weight just to improve my life. That would be inappropriate.

    But, If I’m on my own, I would like guidelines from reputable medical sources so I have a way of evaluating weight loss programs to see which are effective and safe, and which are useless or even dangerous.

    Is there a public health or medically approved website which can give me that information?

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  2. I only wish it were another nail in the coffin, at least on my side of the U.S./Canada border. The message I get constantly — from my latest doc’s office, my employee wellness program, The Weight of the Nation and the U.S. Preventive Task Force — is that I am intrinsically unhealthy despite excellent health measures an diet/activity habits. I don’t see much budging on the issue here, despite increasing evidence that BMI is a poor way to assess risk.

    I think calling the U.S. Preventive Task Force’s recommendations “hopelessly irrelevant” is too kind. I would call them harmful. They are perpetuating a wrong-headed approach to health that has adverse consequences for many.

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  3. Hallelujah!! They are finally seeing the light!

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  4. Great news but I wonder how long it will take for this idea to reach the general population – for example, life insurance companies who deny me because of my BMI of 35…yet I am perfectly healthy – good cholesterol, no hypertension, diabetes or anything other than my spinal cord injury which has not even caused me a UTI for years let alone any other complication….and I’m just 30.

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  5. I’m only reading your summary and not the original research, but my reaction is – so what? I come at this primarily from the standpoint of insurance companies, long-term costs, far beyond 6 years. I’d rephrase this research in terms of smoking as “after adjusting for lung cancer, 1 year survival was only moderately associated with smoking”. I don’t think anyone thinks “get fat, die in 6 years no matter how old you are.” It’s something that can take 20 to 30 years to see full effect, a progression. it’s not cause and effect at a 100% rate, but obesity places pressure on joints which cause a lifetime reduction in mobility which sets in motion all the other problems. One person in 10 might get off scott free, and one person in ten might live a disabled but long life and… But as an actuary (and as a human) I think about loss of life in terms of the best part of life, when you have the energy to be fully functional at work and with kids and parents and on weekends and vacations. And your research shows, over and over and over again, how difficult it is to reverse the course if you wait until the joints are gone and the diabetes and hypertension have set in.

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