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Moving Forward With The Edmonton Obesity Staging System

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.

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


  1. You most also consider the duration of obesity in relationship with mortality.
    Risks increase with numbers of years you have been obese. Diabetes related to obesity takes 10 years to develop, CHD takes 25 years to develop in obese people.

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

    What a courageous question! So many scientists do not ask these very core questions. Actually, most of your colleagues won’t even take this line of questioning with regard to the conventional wisdom: What does it take to reverse obesity and does that activity (diet restriction, generally, paired with exercise) improve prognosis? Answer: It probably doesn’t. Reversing a Stage from the EOSS is very different from merely losing weight, in that it addresses the co-morbidities and only uses weight loss when it might be an effective tool.

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  3. If I were to pursue a PhD, the main question I would want to investigate is one of those you posed — what are the things that “reverse stages” or help maintain people in stages 0,1, or 2?

    I realize that the patients you see are actively seeking to lose weight. However, polls of the general population show that while the weight loss industry continues to thrive, there are many, possibly even a majority, of individuals who are not seeking, or no longer seeking, to lose weight. So, rather than continue to push a “lose weight to be healthier” message — would a public health message that focused on “eat in a pattern consistent with health, move more and in enjoyable ways and see your health care provider regularly to help manage any acute or chronic conditions” be better? It is my observation that there are many people who mentally shut the door on messages that contain a weight-loss focus, and would be more receptive to one that contained a “heath can come in many sizes” message — and included encouragement for people to connect with their health care providers to manage conditions that can lead to complications (including increasing weight).

    A personal anecdote here — when I was diagnosed with type 2 diabetes, I was 25 years old, and 250 pounds. I lost weight rapidly following a 1200 calorie diet and starting an exercise program. After about a year, I was down to 185 pounds. My doctor was thrilled, and said to me, “you know, people often lose weight, and then are reluctant to see their doctors once they start to gain it back.” Sure enough, when I could no longer maintain the 5 a.m.-8 a.m. schedule at the gym and started eating things like candy bars (and “normal foods” in larger amounts) I did slowly gain the weight back, right up to where I had been before. In part, I didn’t maintain my newfound behaviors because I knew 185 wasn’t good enough for anyone else — my doctor, my friends, and strangers still saw me as “too fat” — although I was toying with the idea of trying to maintain at that weight.
    I felt ashamed to go back to my doctor because I felt that I had failed — even though she knew weigt regain was common. I eventually found a doctor who didn’t put my weight as the central issue, she was more concerned about diabetes, and when I started on metformin I lost some weight, and I was motivated to exercise more and eat in a pattern that meant my diabetes was better controlled, because that’s what we focused on, not weight. That set me on a much healthier trajectory. That doctor never made me feel “less than” or guilty because of my weight — she was caring, accepting, encouraging. I miss her — but I moved away from the area where she practices. I have a doctor who is also caring, accepting and encouraging — always asks me about physical activity, always treats what is going on in terms of labs or symptoms, without focusing on weight — if we talk about it, it’s because I bring it up. These days, my weight is around 210-215 pounds, and relatively stable, along with a very active, busy life, and my A1C has been 6.0 or less for about the past 8 years.

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  4. Are there really patients, who never progress?

    There are many people who never progress until they’re in the normal age range to have the chronic diseases of aging, which in this system are positioned as results of obesity. Since everyone dies (and most people die from the issues that the doctors associate with obesity) almost everyone, including thin people, eventually contracts obesity-related health problems.

    Here’s something to think about: there’s strong evidence that losing weight does not improve health outcomes for people over the age of 65. When obese people over 65 start having these problems, is it really a good idea to recommend weight loss?

    Also, I guess when I had my damaged hip replaced, I reverted to stage 0 from a temporary stage 2. Didn’t lose weight, though.

    Oh, and paul boisvert? You’re wrong in making such a sweeping statement. Type II diabetes runs in my family, I’ve been “obese” since childhood (by BMI), I’m 42 now, and I’m not even insulin resistant. I suspect that I’m one of those people who will start having serious health problems at age 70+.

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  5. my grandmother died at age 92, her mother died at age 92, her mother died at age 92, her mother died at age 92, her mother died at age 92 (no my keyboard is not repeating itself) All these women were well-fed (well to do & well educated family traceble to 1566), as being thin was never a health prescription until we hit the 70’s.
    I am Dutch and I see around me hundreds of women who reach 100. All these women were not thin when they were 40!! as thin was not fashionable nor considered healthy when they were 40.
    at the moment I have a BMI of 45, and I used to have a BMI of 26 even when I am size 4 or 6 (and yes for over a decade of my life I had that due to my migraines probably)
    My brother who is slim and well proportioned at 6f 3″ has a BMI of 27. All my life people have judged me on my weight.
    However, I am definitely a stage 0 person and have been so for many years. I am 54, size 18 or 20W, 1.61 centimeters, and an example of health. I have not even 1 symptom of anything! I have suffered from migraines all my adult life most badly so when I was size 4-6. But for the rest I do not have 1 (sic!) medical condition, absolutely nothing.
    I have the heart rate of a 20 yr old, the blood pressure of a 20 yr old (80 over 120), cholesterol levels to die for (not to die of). BUT I AM ONLY JUDGED on the basis of my WEIGHT by all health professionals.
    They see a short, stout woman and that biases all their other observations.
    None of them can imagine that I eat healthy, but I do and have always done so (because I love healthy foods best even as a child), I don’t smoke or do drugs (and that includes prescription drugs), I don’t drink (I don’t like the taste of it), I am active and happy and healthy. But heaven forbid I am short of breath, because that is judged on the basis of my weight (it turned out to be very low iron levels due to heavy menarche).
    I am fed up with the stupidity of the WHO obesity scale, with the BMI bull shit, with the bullying of the medical professionals who insist that anything, even the common cold it seems, is due to me being overweight
    It would be nice if EOSS was more widely used, But even more so, it would be nice if the medical profession had more respect for patients.
    You are right about the fact that the obesity bias makes me visit even my family doctor more rarely than otherwise would happen.
    I seriously doubt I will ever be a stage 1, unless that illness is due to my progressing age.

    BTW I can tell you exercise does not help as I used to be a serious internationally competing athlete, training 5 hrs per day (swimming), every day, and then I was not thin. Thinner than now because I was much younger, plus I had never dieted, but training that much did nothing for my weight.

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