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The Edmonton Obesity Staging System Is Not A License To Do Nothing!



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

17 Comments

  1. Hmmmm. As I see the world, the most dangerous “license” seems to be afforded to people who are trim. “Oh, she can eat anything. She’s got one of those metabolisms.”

    Well, just because she doesn’t get fat doesn’t mean she won’t make herself unhealthy if she eats crap and remains sedentary. She may have genetic luck with regard to weight, but if diabetes runs in the family, she’s screwed if she lives unguardedly. Trim people get diabetes too. And sleep apnea. And all the conditions “associated” with excess adiposity.

    I knew a parent with thin children who used to keep a horrible processed junk food collection for them in a low drawer, so they could just have at it, at will. “Oh, they run it off,” she’d say. Yeah, sure, but are they refueling on anything that’s going assist the cell development of their muscles, bones and brains? I never saw those kids eat anything healthy. It made me sad.

    No, the dangerous license, clearly, is NOT your staging tool. Yeesh.

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  2. Thanks for emphasizing the points in your original article. There is no “us” and “them” any longer with regard to professionals and the rest of the world who are overweight and obese – we are now all in the same boat, and it is tempting to abandon our critical training with regard to evidence and default to emotional wishful thinking on both fronts – the license to ignore obesity because it’s not so bad, and alternately pushing primarily useless weight loss to everyone.

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  3. I really like this article! It’s just such obvious, humane, common sense (and evidence-based for the win!). I would like to nail it to the office door of the doc whose ‘get thin or die you lazy glutton’ speech triggered my most recent depression and EDNOS episode – which lasted three years. Three years I basically don’t remember, don’t want to remember, and won’t get back. Really not that different than dieing three years earlier than I otherwise would, except once you’re dead you’re not suffering like I did during those years.

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  4. Hi Dr. Sharma:
    After having read seveal of the articles on the EOSS plan I find it much more detailed then BMI or even BMI and waist circumferance as the majority of people who do not understand obesity are ready to dismiss the latter two thinking that they are healthy and not realize the invisiable health issues of obesity. Few if any obese people look an cholesterol blood pressure and blood sugar disorders adverse side effects of being over weight. Even fewer look at sleep apneia, fatty liver, or decreased mobiltiy due to aurthritis. The EOSS looks at these segmants of life as well and that makes it particularly a more useful set of critiria for rating health and obesity.

    The media should be banned from reporting on obesity because they always put it so simple that the veiws are more likely to be misinformed versus informed. This misinformation only helps to create and hightens the prejudice that is often present.

    When I look at information I am careful to comprehend the exceptions and limitations, because these two factors can really change the meaning of reading material especially when it comes to reseach based literature. I do think that other readers should be careful when reading research material. This will also help prevent people from thinking they do not need to do anything about adverse weight because low levels of health risks can develop to higher risk fairly easily. Therefore, for 15% who are healthy but over weight not should keep an eye on there weight in case that changes–and it can change.

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  5. Even sadder is the people who have decided that they somehow “know” what is “healthy” and what is “horrible processed food.” From this post, it sounds as if any food that is “processed” is the same as poison. The numerous diet “studies” are all association studies, and there is very little reliable about them. Many are based on people’s recalls of what they eat; as Dr. House says, people lie. Others are based on highly biased subject selection, shaky statistics, and other highly dubious “scientific” conduct. Furthermore, there could have been a dozen studies saying that whatever-it-is isn’t correlated with whatever surrogate measurement (i.e., cholesterol, blood pressure, etc.) for actual good health, but the one study that says it is is the one that got published.

    I think DebraSY needs to get off her high horse and try to understand her level of ignorance.

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  6. The only way fat can enter the body is through the mouth. If you eat those said healthy foods that are fattening…and there is such a thing, then ta-dah. Know what you are eating.

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  7. Thank you for the clarification, it was warranted, misinterpretation of medical information is a vivid and shocking area.

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  8. Hello Dr Sharma

    Thank you for the clarification, it was warranted, misinterpretation of medical information is a vivid and shocking area. I was reading some information on ‘Fat year’ (This was the name provided by the author), which is corresponding to the length of time an individual has been overweight or obese, and if the duration of being overweight or obese has an impact on the mortality and morbidity? Did you and your colleagues try to incorporate this parameter in your development of the EOSS?

    Kind regards,

    Sadiq

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  9. I’m 5’3” woman, 220 lbs. My recent annual physical showed I have no medical problems at all. I’d be EOSS 0, I guess.

    But I’m on a diet/exercise program to lose weight – not for medical reasons, for cosmetic reasons. I’d like to be able to buy and look good in clothes I like. Also being fat makes me awkward and unable to do things I want to do, like get in and out of a kayak. And although I have no disease, lugging around the extra fat makes me walk slowly and tire easily, especially on uphill walks. Try wearing a 70 lb backpack all day, every day, to see what I mean.

    I certainly don’t expect any help from the taxpayers’ medical system for my cosmetic and lifestyle desire to lose weight. EOSS is good for the medical system to ration scarce resources to the neediest.

    BUT!! Is it really true that weight loss would pose a HEALTH RISK to me?
    No wonder commercial weight loss programs thrive if the best an obesity specialist can say is that losing weight has the potential to do harm.

    1.” People COULD do unhealthy weight loss practices “- but not necessarily – people can and do follow healthy weight loss practices.
    2. “loss and regain may have negative consequences. ” Maybe for some, but at least -10 and then +10 is better than no loss and then +10. Every weight loss gives you the chance to learn what works for you and what doesn’t, so you can use what you learn to develop a weight loss/maintenance plan. Expecting people to lose weight perfectly consistently, with never a relapse or upswing is perfectionism that is discouraging and defeating.
    3. “being unsuccessful at weight loss now may make it difficult to lose weight when you NEED to”. This implies that if you NEED to lose weight there is actually a way to do so. Waiting until you’re really sick is not going to make weight loss any easier – in fact it may be more difficult to be sick and also be trying to lose weight at the same time.
    4. “low-risk status applies to only a minority of overweight and obese people” That to me is an indication that I’d better not roll the dice by staying fat and hoping in a few years I’d be one of that very lucky minority.

    You say there are no studies showing healthy obese people develop morbidity IF THEY CONTINUE TO MAINTAIN THEIR CURRENT WEIGHT AND HEALTHY LIFESTYLES! That’s a big “IF”, in fact simply doing that is in itself an effort at PREVENTION of developing health problems.

    Apparently, there is nothing inherently ‘unhealthy’ about extra fat.
    All MY extra fat is, however, a big NUISANCE to me, and I’m going to get rid of it (so far 35 lbs gone). I guess that puts me in the category of those who engage in risky behavior.

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  10. Anonymous, I don’t think anybody’s trying to discourage you from going on a diet if that’s what you want to do. All this means is that Dr. Sharma wouldn’t advise a doctor to tell someone like me – someone who’s around your size, also healthy, and doesn’t find it to be a nuisance or hindrance – to lose weight by any means necessary. It’s not about trying to stop people from dieting. It’s about not automatically pressuring everyone with a BMI above 30 to do so.

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  11. Well, I do want to lose the weight. However, I am reconsidering my first impression of this post.

    As I re-read Dr Sharma’s post I am becoming more and more convinced that – of course – he wouldn’t be warning doctors about potential harm to their patients when they lose weight if the threat of harm wasn’t SIGNIFICANT and SEVERE.

    If weight loss is dangerous to health, then I’m going to make sure my family doctor follows my diet/weight loss every step of the way.
    It will be less of a burden to the health care system if I am under a doctors care all the time, right from the start, and so avoid all the pitfalls Dr Sharma describes.

    If I try to do this on my own I could get myself into big trouble, as he points out, I could inadvertently use unhealthy weight loss plans, I could yo-yo which has bad consequences, I could get sick and find myself needing to lose weight and at that time being unable to, and I could be unsuccessful in losing or maintaining weight on my own and end up with “morbidities”.

    As I re-read this post about the dangers of weight loss I come to the opposite conclusion than I did at first glance.
    If an obesity specialist says there is potential for harm in weight loss, then that has to be taken seriously. Weight loss is the goal because the weight is a disability. (It doesn’t bother you, but being obese negatively affects what I can do in my life). But weight loss isn’t a DIY project, it has a potential for harm, and the best way to avoid that harm is by being under a doctor’s care.

    So, DeeLeigh ( and Dr Sharma) I am taking this post to heart and making appointments with my family doctor to do this under proper care. A doctor wouldn’t offer treatment with the potential for harm unless there is worse harm by NOT giving treatment. (That’s true in a lot of medicine.) Overcoming my disability due to obesity is worth dealing with the potential of harm – but that potential of harm has to be minimized as much as possible, so this isn’t a DIY, a doctor’s care is needed.

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  12. Anonymous-

    Or you could just work on improving your eating habits and getting more active in a sustainable way – adopting habits that you feel like you could keep up indefinitely – and simply let your weight adjust. That way, you can address any functional issues you have. For example, if you walk every day and work on pushing your pace, then you’ll be walking faster in no time and eventually you can advance to running if you want. Your body will learn to do what you ask of it. It’s not about weight. It’s about the targeted strength and endurance you develop when you’re doing something regularly. To get better at something physical, you have to practice.

    That’s why I don’t feel uncomfortable at my size. I cut myself some slack here and there for things that are harder for me because I’m heavy, but for the most part I do what I want to do, and my body adapts.

    I’m not in any way saying it’s bad to lose weight. I’m just saying that most people can make huge improvements in their health and functionality without focusing on weight loss, and that it tends to be a more positive, sustainable way to do things for many people.

    Just putting that out there…

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  13. You are assuming that I’m eating badly and doing nothing. I have worked to improve my diet and get as much exercise as I can. The fact that I am healthy according to a medical physical exam, blood tests etc, is evidence of that. However, my weight is not “adjusting”. I still have to carry around 70 lbs of fat.(At 70 lbs lighter I would still be considered Overweight, I’m not trying to be fashionably slim).
    To lose the weight I have to go on a weight loss diet, and as Dr S posts, that has a potential for harm, so it should be under a doctor’s care.

    You “cut yourself some slack” and “for the most part, do what I want to do”. Excellent.

    I have already stopped doing many of the physical activities I used to enjoy, because I got too fat. Now a walk is about as much as I can handle.
    I suppose I could be grateful I’m not in a wheelchair, accept that I am permanently limited by my weight, sell my kayak (nobody actually NEEDS to go kayaking) and live within the limits imposed by the fat.

    The problem is I’m not ready to give up yet. I want my life back.

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  14. Hey, anon, I was just putting an idea that many people have never thought about forward. Obviously, you are unique and you know more about your situation than anyone else.

    I just don’t understand why you’ve stopped doing the things you enjoy. Being fat doesn’t have to stop you from doing things. If you do them, you will develop the strength and endurance you need. At least, that’s how it works for me and most other people I know. Hell, a 400 pound man recently ran the LA marathon.

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  15. That’s like saying to someone, I just don’t understand why you don’t lose the weight, look at this magazine cover , she lost 200 lbs.

    I have no desire to run a marathon. I do want to get rid of this fat. So I will devote my strength and endurance to that end.

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  16. I think we are getting lost in whats a risk factor, or a disease, or a syndrome, and as usual we don’t know what we don’t know, what we can’t see, what we can’t measure. So are the only important measures heart disease, cirrhosis, and diabetes? Its clear Anonymous’s life is being impacted by her obesity, and I think she would feel better, function better, and even live longer and healthier, if she mananged to eat a lot less, have weight loss surgery, take a yet to be invented pill, or ZUBA.
    I think the concept of a healty range for weight is the same idea as a healthy range for blood pressure, a healthy range for varoius blood tests, and a healthy range for hours of sleep.
    This is a very impotant discussion to be held, especially for health policy makers.

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