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Edmonton Obesity Staging System

Regular readers of these pages may remotely recall that last year I complained about how BMI does not always allow us to make rational clinical decisions regarding obesity management, because measures of weight (such as BMI) do not reflect severity of obesity in a given individual. In that post, I discussed several options of further classifying obesity based on clinical parameters that would guide management.

Following the tremendous positive response on that earlier posting, I invited Dr. Robert Kushner, President of The Obesity Society, to join me in writing an article in which we propose a 5 stage system that would allow clinicians to grade obesity based on simple criteria obtained from medical history, physical examination and standard diagnostic tests.

This article is now published in the International Journal of Obesity and also provides a brief history of obesity taxonomy and classifications together with a discussion of their shortcomings.

As described in the paper, our proposal defines 5 stages of obesity ranked according to increasing severity.

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 and/or impairment of well being.

STAGE 1: Patient has obesity-related subclinical risk factor(s) (e.g., borderline hypertension, 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 established obesity-related chronic disease(s) (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or well being.

STAGE 3: Patient has established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitation(s) and/or impairment of well being.

STAGE 4: Patient has severe (potentially end-stage) disability/ies from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitation(s) and/or severe impairment of well being.

Given that obesity treatment requires considerable efforts and resources, we suggest a pragmatic approach to managing patients at the different stages of obesity:

For STAGE O: Identification of factors contributing to increased body weight. Counseling to prevent further weight gain through lifestyle measures including healthy eating and increased physical activity.

For STAGE 1: Investigation for other (non-weight related) contributors to risk factors. More intense lifestyle interventions, including diet and exercise to prevent further weight gain. Monitoring of risk factors and health status.

For STAGE 2: Initiation of obesity treatments including considerations of all behavioral, pharmacological and surgical treatment options. Close monitoring and management of comorbidities as indicated.

For STAGE 3: More intensive obesity treatment including consideration of all behavioral, pharmacological and surgical treatment options. Aggressive management of comorbidities as indicated.

For STAGE 4: Aggressive obesity management as deemed feasible. Palliative measures including pain management, occupational therapy and psychosocial support.

As outlined in my earlier post – this Staging System is to be used together with the conventional BMI cutoffs.

In a world of limited healthcare resources and an already huge burden of people with obesity, we believe that the “biggest bang for the buck” will come from treating individuals with Stage 2 or 3 obesity. This of course should not divert from the efforts at prevention and halting the progression of obesity in individuals with Stages 0 and 1.

Judging by the early media response to this article, I assume that this paper will initiate a broad discussion not only on how to refine this system but also on whether or not this system will in fact be found effective in better managing patients struggling with excess weight (we are already piloting this system in our Edmonton clinic).

Appreciate all questions, comments and suggestions.

Edmonton, Alberta


  1. Congratulations on the article publication. This staging approach seems like a very good way to fill the gap between BMI diagnoses and treatment decisions. Thank you for taking a common sense approach to grading obesity-related health issues.

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  2. Arya,
    Congratulations on your article. It seems useful to have a staging system of intervention since not all patients with obesity suffer equal morbidity. I will send it to our clinicians at Emory Bariatrics and let you know any feedback I get. I also look forward to the results of your pilot study.

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  3. This staging is a very practical approach to a very complex clinical picture.
    This helps define the degree of efforts a physician should expend in treating different stages and clinical presentations of obesity.

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  4. I liked your article very much. If indeed the cutoffs aren’t completely inclusive or exclusive it helps a lot to improve the clinical judgment and comprehensive mangament of people with obesity and it will surely motivate further understanding of the conditions associated with it. I have seen a couple of patients with BMI >40 with no complaints (not even knee osteoarthritis) except for their worry ness to be sick and a lot others with overweight who suffer from conditions most probably promoted by body fat, so I think the article is a step forward in clinical management of obesity. Congratulations!

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  5. Arya, you are already aware that I am your biggest fan, and our clinic prides itself in following the guidelines that you establish. We have been using the EOSS for months now, prior to the publication. The majority of the 2000 pts at the Wharton Medical Clinic have been assigned with an EOSS value. I ensure that my consult notes indicate that the EOSS is credited to Sharma and Kushner, and I include a copy of the full table. I believe this is a great educational tool for the physicians who refer patients to our clinic. It is now part of our searchable parameters. We would love to collaborate with others as they use the EOSS to determine the usefulness for bariatric physicians and for the family doctors who receive our consult notes. Bottom-line – thanks Arya and Robert for this great addition to our field.

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  6. I just read the article in MacLean’s and I was thrilled that a shift in thinking is finally occurring. I think the staging system is fantastic, and if widely used, will help patients immensely. I’ve had some pretty ridiculous things said to me in a doctor’s office based on weight alone, without taking into account my lifestyle and other factors. It would be great, from a patient perspective, to be able to be treated much more individually than the BMI allows. Thank you so much!

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  7. That still does not answer the question as to whether weight loss benefits people with disease risk factors. Yes, it “fixes” the surrogate measures (A1C, lower cholesterol, etc.), but there is still no proof that weight loss benefits an obese person in terms of a reduction in the absolute risk of severe outcomes in morbidity and mortality.

    There is an article in the Journal of Nephrology from last year written by Dr. Nortin Hadler, MD that offers convincing data to show that the current treatments for problems related to type 2 diabetes are largely ineffective in doing anything other than just treating the numbers.

    Also, this from a great health blog:

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  8. This makes so much sense. If only the AMA would pick on properly identifying obesity. It is extremely progressive and should be analyzed this way!

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  9. Thank You! I just saw this on the news and I think that this is a fantastic new classification system. I hope this information spreads to the people who need to know it, such as:

    1. Overweight and obese individuals who have low self-esteem and body image;
    2. Anyone who has a stigma against overweight/obese individuals;
    3. Employers who shy away from hiring those with weight issues.

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  10. I do not have the password to read the original article, but from your description it seems that this measure could be confounded by age. People who have diabetes or heart disease as a result of obesity tend to develop these conditions after years of exposure. When the authors compared mortality rates among the different classifications, they would naturally find higher mortality rates among the group with more years of exposure, which would tend to be older.

    A separate issue: Unless the analysis included a longitudinal component to account for the disease process, I worry that this article will take the focus away from patients where intervention could prevent disease. An overweight patient with CHD, PVD and diabetes has the highest risk of mortality; but the time to intervene is long before that stage.

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  11. Dr. Sharma,

    I didn’t learn of the EOSS you developed until the Canadian Medical Association Journal published research using your EOSS on August 16, 2011. Way to go!!! This system has a great potential for studying and addressing the worldwide obesity epidemic. I hope this system will be used widely across the world because it accounts for all the important variables to consider when addressing obesity issues. Just looking at BMI is not enough. Thank you!

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  12. Dear Dr. Sharma:
    AT LAST, someone with the sense to realize that not all “frames” are the same. The daughter of two athletes, I have been “big” and heavy most of my life and always was striving to reach 145 lbs. which my BMI would indicate as acceptable. I did achieve that — eating 700 calories a day. Not healthy, and not sustainable. After years of yo-yo dieting, I am now 72 years old and over 200 lbs and still “Stage 0” on your scale. I eat an excellent diet and exercise regularly at the gym. I probably would feel better if I lost 20 lbs, but the unachievable has driven me into a corner.
    Joann Lamb

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  13. I am horrified that quite overweight people can now find an excuse to not lose weight on the basis of this. One lady on the CBC news last night proudly announced that as she did not have diabetes or hypertension’, she was reassured about her obesity.
    It has been reported that 30% of kids under (I believe it was 12) 12 are obese!. Many of them will probably not have clinical criteria which would now put them in stage 0. Which is quite ridiculous and irresponsible
    The classification above makes no mention of age which I find incredible as, stage 0 persons at say age 25 may well degrade to the later stages in a short or a longer time. It is russian roulette. If you are overweight, get it OFF, or probably suffer the consequences in, perhaps, the not too distant future.

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  14. @ Knox — you are assuming there is no risk to intentional weight loss. Many people can attest to dieting themselves up the scale. It can be difficult to get adequate nutrients on a severely calorie-restricted diet. Dieting can result in muscle loss and interfere with serious athletic training. (The Dukan Diet — which I consider pure starvation — in fact, recommends that you do not exercise seriously while on it.)

    If you offered me any other medical intervention with a 5% success rate and a 33% chance of making things worse, I’d tell you to go jump in a lake. There is no downside, however, to following HAES recommendations to eat a healthy (not restricted) diet and increase physical activity.

    And yes, I am overweight and quite healthy and athletic with a stable weight. I fail to see how starving myself will improve my health. It’s time we had a sane conversation about health vs. weight.

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  15. Youre so cool! I dont suppose Ive learn anything like this before. So nice to search out somebody with some unique thoughts on this subject. realy thank you for beginning this up. this website is one thing that’s needed on the net, someone with just a little originality. useful job for bringing something new to the internet!

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  16. I?d have to verify with you here. Which isn’t one thing I usually do! I get pleasure from reading a put up that will make folks think. Additionally, thanks for permitting me to remark!

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  17. Don’t you know that Americans cure obesity through shame and loathing? It works! It worked for me! I was five pounds overweight and my friends never stopped telling me how disgusting I looked, and I chose to go back down to a healthy weight of 90 pounds! It works!

    You fatty sympathizers! How dare you approach obesity, the number one crisis in America, with a sense of consideration and rationality?! You want to throw your lot in with the disease-ridden dregs, then you will bathe in their fat blood with them!

    I am the healthy one! I AM THE HEALTHY ONE!! AAAAUGH!!

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  18. I think I love you. I was fine until my doctor told me I had to lose weight, when I was 5’5″ and 165 lbs. Now, after numerous diets and a couple of babies by c-section, I am 240 lbs. Needless to say, I stopped dieting. I am working on ramping up my exercise and seeing a therapist for Binge Eating – which I never did before my diets. My “numbers” are normal still, the only slightly elevated one is by blood glucose, and it is still within normal range, just in the high end. I really hope that doctors listen to you and that other people don’t go through the shame and guilt of putting on more weight even though they have tried so hard to lose weight.

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  19. I had the priviledge of hearing Dr. Sharma in Edmonton at a chronic disease management seminar. When i saw the conference outline, I was fully prepared for another healthy dose of guilt, shame, and remorse to remind me that I am too fat and at high rist for dying prematurely. The change in perspective is refreshing, particularly since I am a stage 0 person. I like the idea that obesity should be approached as a lifelong chronic disease involving lifestyle change as treatment rather than a character flaw that requires a quick fix fad diet as a cure..
    My personal experience with doctors has been that they are far too quick to judge and far too quick to blame unknown health complaints on obesity. Case in point…I spent 2 and a half years being sent from specialist to specialist for difficulty with stomach and lower groin pain. All of them said I was ” morbidly obese” and recommended various weight loss programs or bariatric surger without any further investigation. all assessments were based on BMI, which is about 42. None of them took the time to explore my concerns, they were all too happy to brand me as another fat lady with no will power. I finally found a surgeon who listened and took the time, ordered the appropriate tests, etc. and acted on the findings. In the end he removed twenty pounds of lipomas ( fatty tumors) that no diet would ever have resolved.

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  20. Well, as many commentators have already pointed out, the main problem i have with the staging system is that it does not consider age in the staging and there seems to be an assumption that one does not progress between the stages. As i see it, nothing stops someone at stage 1 from progressing over time to stages 3 or 4 especially if they take home the message that being at the earlier stages means they are not at any long term risk and therfore don’t do anything to lower their risk. I think the message should be emphasised that no matter how low your initial stage, you should still seriously apply the lifestyle changes that will help prevent your stage from deteriorating.

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  21. @agboju ode: actually that is exactly what we say in the paper and on the figure: even at Stage 0 you need to focus on healthy eating and increasing physical activity in order to prevent progression to stage 1 (this may not require weight loss). Halting progression at every stage is a key message of the staging system.

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  22. @Arya M. Sharma: Thanks, i wasn’t able to access the paper earlier, but I’ll definitely read it now.

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  23. On the other hand, unintentional weight-loss is surely an unconscious means of slimming down. This occurs mainly caused by illness as well as physical complications. Among the signs of …Edmonton Weight Loss

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  24. I will like to know the Journal in which this functional obesity staging system has been published so as to apply it in my present study in NIGERIA reference it as appropriate. It is a very good and clinical friendl staging system.

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  25. What would it take to make it standard procedure for MDs to note the EOSS in an examination? It’s seems self explanatory, and coupled with BMI (though, insignificant to body mass and waist ratios) it would give a decent score. As a mental health counselor, it is seems it could be used in accordance with a GAF score to determine risk.

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  26. Hi Dr Sharma,

    could the EOSS be use to guide treatment of pregnant obese women instead of using only the BMI? For example, some of our local hospitals have special protocols for women with a BMI of 40 or more, even if this is their only risk.

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  27. Hi Dr. Sharma,

    I’m curious about where I would fall on the system. I have about 250lbs to lose and I do have sleep apnea, but I was first diagnosed with sleep apnea before I was even overweight (I had surgery for it at age 7). I guess the surgery wasn’t particularly helpful because I still have sleep apnea now at age 33. Other than that, I have no diabetes, high blood pressure or anything else. I am not as fit as I would like to be and it takes me 25 minutes to walk a mile on the treadmill, but I’m working on it.

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  28. My dearest friend is 63 and is morbidly obese. She is diabetic who has ulcer on bottom of foot. Communication is poor with family doctor. She has three treatments of Iv antibiotics and need pump on foot. Hgb a1c great. Clots yes. After surgery lodged in lung. Lived.

    Attitude of husband is to kottle her. Treats her like child.

    She eats and takes meds that are not best for her.
    Her brother poisons her with his fatty diet.
    I want to help her as she wants help

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  29. Hello, Dr. Sharma,
    I ‘m researcher of Federal University of Rio de Janeiro and i found EOSS very interesting. I’d like to improve this method in our clinic that assist obese and show to our students in University. But i’d like to know if EOSS has validating for any organ.
    Thanks for your attention.

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  30. Thought-provoking post ! Just to add my thoughts , people are wanting a PBS Checklist of ADL , my boss came across a sample document here

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