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To Lose or Not to Lose?

Yesterday was an odd news day for me.

Following the widely reported CanWest story by Sharon Kirkey, in which I am quoted as saying that not everyone, who meets the BMI cutoff for obesity needs to run out and lose weight, I was also interviewed by CTV on a new study, just published in The Lancet, which confirms that obesity does increase the risk of death.

This study, authored by the Prospective Studies Collaboration, examines the relationship between body-mass index and cause-specific mortality in 900 000 adults combined from 57 prospective studies – a BMI between 30—35 reduces survival by 2—4 years; at BMI 40—45, life expectancy is reduced by 8—10 years (which is comparable with the effects of smoking).

The obvious question is how to reconcile these two statements.

Here is how:

While we know that obesity increases the risk of dying, we also know that BMI is not a perfect measure of health. This is exactly why we introduced the Edmonton Obesity Staging System, where we stage obesity based on the actual presence of risk factors or comorbidities rather than on BMI alone.

The rationale for this is simple: while excess weight is certainly a health risk when it actually affects your health, in some people the health impact of even moderately excess weight appears to be minimal (see the Kirkey article). Because excess weight does not kill you in an instant and most negative health consequences of obesity, if addressed early, are reversible, you still have plenty of time to tackle the excess weight, once you have the first signs of obesity related disease – thus, hypertension, diabetes, dyslipidemia, sleep apnea, and many other health consequences of obesity are all completely reversible with weight loss (it turns out that obesity related cancers may be an important exception to this rule, as the onset of cancer may be insidious and by the time it is diagnosed, treatment may come too late – which is why I would strongly recommend that anyone with excess weight diligently follows cancer screening guidelines).

Given that weight management requires dedication and resources, and is seldom achieved in the long-term without professional help, requiring everyone to go out and lose weight even if there is no evidence of a weight-related health problem would completely “clog” the health care system. It therefore makes sense to begin addressing excess weight, when patients reach Stage 1 obesity, or in other words, develop the first signs of weight-related health problems.

Till then, the focus should be on prevention of further weight gain (a difficult enough venture) and on making lifestyle changes that include eating as healthy as possible and getting a healthy dose of daily physical activity.

Edmonton, Alberta


  1. On reconciling risks of obesity vs. cost of prevention: Tell the patient the facts!!

    If a doctor makes a good decision to not treat obesity in an otherwise healthy patient, because of cost considerations, that reason should be made clear to the patient.

    The doctor shouldn’t say “You’re obese but you’re fine”

    The doctor should say ” Because you’re obese you’re at increased risk of disease and death. However, you won’t get treatment for obesity because it is more cost effective to wait and treat you only if you get sick.”

    It may not clog the system to treat only those who get sick, but for those unfortunate few, the cure is much worse than prevention. They still have to loose the weight, and they have to do it while they’re sick and fighting obesity induced disease.

    If patients think “My doctor isn’t treating my obesity, so obesity can’t be dangerous”, they’re not motivated to loose weight.

    If patients knew “My doctor isn’t treating my obesity because it is better to let me take the risk of disease and death than to clog up the system”, they might be more motivated to loose weight. After all, they could be among the unlucky ones who don’t beat the odds and who end up obese and sick.

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  2. A patient’s voice here..
    Each person’s risks are different.
    My risks are specific and the treatment for my “co-occuring” conditions sometimes leads to weight gain, as does the condition itself.
    For me, regular physical activity and eating well are important, whether they lead to weight loss or not.
    No one, not once in my life, has ever said, “you are obese, but you are fine.” — until recently it had been, “because you are an overweight child, you are at risk of becoming an overweight adult” or “losing weight will make this problem go away.”
    If I had been told “there’s a good chance you’ll be overweight throughout your life, so it’s essential to take really good care of yourself, finding exercise every day and eating really well and making sure to have a good doctor you see often” — that would probably have resulted in a healthier outcome than the one that kept me from wanting to see the doctor because I was going to be scolded or made to feel bad.
    There is a difference between “you’re obese but you’re fine” and “you are at higher risk, and here are some things you can do to reduce your risks even if they don’t lead you to lose weight.”

    Dr. Sharma, I admire that you grapple with this and see that not everyone who is fat needs to be viewed as “sick” — and to be aware of what it takes to manage weight in a “chronic care” fashion.

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  3. A couple of years ago after my routine physical the doctor told me my medical tests were all good and because I “moved well” my weight wasn’t a problem. He didn’t talk about increased risks. He recommended the Canada Food Guide and walking. I’m 5’4”, I was 245 lbs.

    I followed his advice, except I probably couldn’t walk fast enough. My weight stayed about the same.

    However, I got totally fed up with being obese, so I started a weight loss program. In about a year I’ve lost 49 lbs.

    So far I’ve been loosing weight for cosmetic and lifestyle reasons. I don’t have any complicating health problems, so weight loss is possible for me. Knowing that my obesity increases risks of disease is an added incentive to continue loosing.

    I agree with wellroundedtype2 that each person’s risks are different. I do think that people should know that obesity has risks, even if there’s no current health problem needing a doctor’s care, as was my case. If there are health problems preventing weight loss, then of course a doctor’s care and other risk reducing tactics are needed.

    (P.S. When he said I “moved well”, the doctor was probably comparing me to his bedridden and wheelchair bound patients. Carrying around 100 lbs all the time and being size XXXL puts serious limits on one’s activities!)

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