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The Edmonton Staging System: Post 2, Discussion

This post is a follow-up to The Edmonton Staging System: Post 1, Basics.

The stated purpose of the Edmonton Obesity Staging System (EOSS) is to predict early death and disease in fat people. It's an attempt to define clinically significant "obesity" without resorting to BMI. But, the conditions it's based on aren't necessarily causally related to weight, so it doesn't really disassociate obesity from BMI. Instead, it associates the diseases of ageing with weight when they occur in fat people. People with BMIs under 30 won't be classified according to the system, even if they have the diseases and conditions that define the stages.


Every disease that kills fat people kills thin people too. Thin people get type II diabetes. Thin people can have high blood pressure, high triglycerides and high cholesterol. Thin people get heart disease and die of heart attacks, all while having BMIs under 25. Many fat people never develop diabetes and/or begin to experience the diseases of ageing at the same time of life that their thin peers do. However, when fat people begin to experience health problems as they age, the Edmonton Obesity Staging System will associate those problems with their weight and consequently weight may be treated as the root cause.

The structure of the EOSS suggests that any health problem that's correlated to higher weight is part of a progressive syndrome called "obesity." In reality, causality is always more complicated than that. For example, family history may play a more important role than weight in diabetes and heart disease, and joint problems may be partly or entirely due to injuries. These factors shouldn't be ignored when another risk factor (high BMI) is present. The way the staging system is structured implies that fat people will inevitably advance within its framework. Conveniently, that's usually true. Why? Because the conditions and diseases associated with a high BMI are also associated with ageing. Almost everyone, fat and thin, moves through the EOSS stages as they age. However, fat people don't inevitably move through them more rapidly. There are fat people who stay at stage 0 or 1 for many decades: 30, 40, or 50 years. An unusually large body is not a progressive disease.

It's not all about weight. If weight were the main factor in health and life expectancy, then we would be seeing much bigger differences between fat and thin people in mortality and morbidity. Hell, thin people would live forever. In reality, fat people don't necessarily die earlier or use significantly more medical resources than thinner people. Maybe the EOSS is partly an attempt to resuscitate the weight based health paradigm in the face of evidence that body mass index (BMI) doesn't do a very good job of predicting mortality or morbidity for individuals - or even populations, except at extremes.

I don't want to get down on the doctors too much. They're not the only ones responsible for the weight based paradigm. In fact, I'm pretty sure that the medicalisation of body size arose in the early twentieth century largely as a response to women's demands for thin, fashionable bodies (and that's a series of posts - or a book - in itself).

To be fair, we're weird here at BFB and in the fatosphere. We're fat people who accept our sizes and want our doctors to do the same. But we are not the majority of fat people.

Many (perhaps most) fat people are desperate to get thin at any cost because of the social stigma, blaming and shaming they're experiencing. Doctors are usually happy to provide "health" as an excuse. The problem is, there is no safe, effective way for most people to lose a significant amount of weight permanently. Every weight loss treatment - from yo-yo dieting to pills to weight loss surgery - has a (sometimes devastating) impact on quality of life and carries significant health risks. The Edmonton Obesity Staging System provides doctors with a way to say "no" to dangerous weight loss treatments for healthy fat people. Why would you provide someone with a normal life expectancy with surgery that could kill her or pills that could damage her heart? This is actually very sane.

The problem is that the staging system creates categories for "good fattie and bad fatties" - it makes healthy fat people into exceptions. However, everyone is going to turn into a bad fattie as they age and nobody, whatever their age or state of health, deserves to have their health problems blamed on their weight and potentially be told to "lose 100 pounds and call me in the morning."

So, if the EOSS is meant to protect healthy fat people from dangerous (and expensive) weight loss treatments based on a rough cost/benefit analysis, then so be it. I just hope that nobody is intending to use it to limit access to treatments for health conditions that are correlated to high BMIs ("hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, and anxiety disorder"). Even when the statistics say that a person's BMI is increasing their risk of disease or early death, it doesn't say anything about causation and it doesn't mean that weight loss will have any effect. Sometimes the condition is responsible for the high BMI, not vice versa. And in any case, everyone deserves good medical treatment regardless or what they weigh and regardless of whether or not they lose any weight.

I think all fat people would agree: if we experience a health problem, we'd like our doctors to use the same treatment plan that they would if we were thin. Even people who think that their weight is a problem that can be fixed still don't want to be denied treatment based on it.



Instead of providing a blow-by blow of the research behind the EOSS and the media coverage of it, I'll leave the links with you. There's a lot more analysis that could be done, here. Hopefully these links will help anyone who's interested in following up.

Dr. Sharma's Blog

These are some of the main posts on the Edmonton Obesity Staging System. There are more.

Research

The Arya Sharma article: Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity, August 15, 2011.

The Steven Blair article: Edmonton Obesity Staging System: association with weight history and mortality risk, August 24, 2011.

Press
And... here's the press coverage. The source for these articles will have been this press release from Canada's National Research Council, entitled "System lets health providers better predict which obese patients are at risk for death – and which ones don’t need to lose weight at all"

The Paradigm Shift | How to Argue with a Fat Loather

vesta44's picture
vesta44
November 18th, 2011 | Link | The main problem I have with

The main problem I have with any system that intends to treat fat people is that none of them can show that obesity causes an increase in morbidity (disease) or mortality (death), nor can they show that any of their recommended treatments will create a decrease in morbidity or mortality. Even the U.S. Preventive Services Task Force website (found here) on obesity hasn't found enough evidence or enough studies with enough evidence that obesity increases morbidity or mortality, but they still recommend weight loss and exercise to lessen a risk that evidently doesn't exist. Talk about sticking one's fingers in one's ears and going "la la la, I can't hear the evidence contrary to what I think is happening", the USPSTF is doing it, as well as everyone involved in creating the EOSS.
And while the EOSS may be intended to be used to ration WLS, so that only those who are in dire straits actually get it, I'm afraid it's going to end up being used to justify rationing all kinds of care for everyone who's fat. I'm very afraid it's going to be used to divide fat people into the "good fatties" and "bad fatties" and only the "good" ones are going to get necessary health care, while "bad" ones are going to be made to meet some arbitrary standard before they can get their health care (prove you're following some diet plan, prove you're exercising so many minutes a day, etc).
Idealism is all well and good, but when it meets the real world, I'm afraid the idealism of what the EOSS should be, was meant to be, is going to fall by the wayside and end up being used to fulfill some governmental agenda.

WLS - Sorry, not my preferred way of dying. *glares at doctor recommending it*

kmom November 19th, 2011 | Link | It's an excellent point that

It's an excellent point that *everyone* - regardless of weight - moves through these stages as they age, sooner or later. It's a rare person that doesn't develop *something* as they age. But in fat people, it will inevitably be attributed to their weight and weight loss will be the prescription.

I appreciate what the authors were trying to do, and don't think this study is all bad. But I too am concerned about the 'good fatties' vs. 'bad fatties' perception and the collateral damage from that.

I think the fat folk who do develop complications often develop them secondary to other issues, like PCOS. This deserves treatment, but it doesn't necessarily have to involve mandatory weight loss. Blaming it on fatness alone keeps them from investigating and addressing the real underlying causes (whatever causes PCOS, for example). Fatness is often a symptom, not necessarily a cause. But if we blame fatness, we don't have to look more closely at other possible issues. Is that really going to improve fat people's health?

I read the abstract for the Cooper study linked above. I've not read the full text yet, but I find the following statement ironic:

"Lower self-ascribed preferred weight, weight at age 21, cardiorespiratory fitness, reported dieting, and fruit and vegetable intake were each associated with an elevated risk for stage 2 or 3. Thus, EOSS offers clinicians a useful approach to identify obese individuals at elevated risk of mortality who may benefit from more attention to weight management."

So dieting was associated with an elevated risk for Stage 2 or 3 (obesity with complications), but our prescription is going to be "more attention to weight management"? And what about the research that shows an increased risk for mortality from intentional weight loss or weight cycling?

http://www.ncbi.nlm.nih.gov/pubmed/17676383 Rhezak 2007
http://www.ncbi.nlm.nih.gov/pubmed/20065967 Ostergaard 2010
http://www.ncbi.nlm.nih.gov/pubmed/21336426 Perez Morales 2010
http://www.ncbi.nlm.nih.gov/pubmed/15847242 Diaz 2005

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