1. How to stage patients with obesity
Carel le Roux
Diabetes Complications
Research Centre
University College
Dublin,
University of
Gothenburg

3. Morbid
obesity
vs
Obese
morbidity
Sharma et al
CMAJ 2011

4. Do you want to Medicalise this man?
Physically active
Happy
Employed
120/78 mmHg
Normal glucose
and lipids

5. Indication for Obesity intervention
55 years
Pipe smoker
3rd
party assistance for ADL
No exercise
148/88mmHg
Fasting glucose 7.5mmol/L
Low HDL, high Tg
+/- Sleep apnoea
Good candidate for
intervention ?

6. Recidivism after volitional weight loss
BMI
Time
40
30
20
Volitional /
pharmacological
weight loss
Homeostatic
response promotes
weight regain
Settling
point
Reduced-
obese state

7. Weight Management vs Obese Morbidity
Clinic Treatment
kg
Weight
management
Stop
coming
Multi-
modal
Strategy
Morbid Obesity Obese Morbidity
10 domain
assessment
P1
P2
P3
Weight sensitive?
Weight resistant?
Non-weight related?
Therapy specific?

8. Morbidity and weight loss sensitivity or resistance
Metabolic
Ventilatory
Reproductive
CV risk
Perceived health status
ADL / QoL
Eating behaviour
Depression
Body Image dysphoria
Economic cost
-5 -10 -15 -20 -25 -30
% weight
loss to
improve
morbidity
Aylwin 2005

9. Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
Medical
MentalFunctional
absent
absent
absent
pre-clinical
risk
factors
m
ild
m
ild
co-morbidity
moderate
moderate
end-organ
dam
age
severe
severe
end-stage
end-stage
end-stage
Obesity
www.drsharma.ca

10. Edmonton Obesity Staging System (EOSS)
Stage 0 Normal
blood glucose
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
IFT/
IGT
Stage 2
Type 2
Diabetes
Stage 3Micro-/macro-
vascular
disease
Stage 4Blindness
ESRD
Type 2 Diabetes
www.drsharma.ca

11. EOSS Predicts Mortality in NHANES III
Padwal R, Sharma AM et al. CMAJ 2011www.drsharma.ca

12. EOSS Predicts Mortality at Every Level of BMI
NHANES III
Padwal R, Sharma AM et al. CMAJ 2011
Overweight
www.drsharma.ca

13. EOSS Distribution Across BMI Categories
NHANES III (1988-1994)
Overweight
Class
III
Padwal R, Sharma AM et al. CMAJ 2011
50 million
23 million
10 million
6 million
www.drsharma.ca

14. EOSS Case 1
24 year-old physically active female,
BMI of 32 Kg/m2
no demonstrable risk factors, no functional
limitations, or mental health issues
Class I, Stage 0 Obesity
- Focus on prevention of further weight gain
- Health benefits of more aggressive obesity
treatment likely marginal
Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca

15. EOSS Case 2
32 year-old male
BMI of 36 Kg/m2
hypertension, sleep apnea, depression
Class 2, Stage 2 Obesity
- Clear benefits of obesity treatment
Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca

16. EOSS Case 3
63 year-old male
BMI of 74 Kg/m2
disabling osteoarthritis (wheel chair)
severe hypoventilation, fibromyalgia, generalized
anxiety disorder
Class 3, Stage 4 Obesity
- Aggressive obesity treatment unless deemed
palliative
Sharma AM & Kushner RF, Int J Obes 2009www.drsharma.ca

17. www.drsharma.ca

18. Key Points: EOSS provides
framework for clinical prioritization
predictor of obesity risk
Basis for management strategies
www.drsharma.ca

19. Obesity Staging Score: Aylwin et al Front Horm Res 2008
Stage 0 Stage 1 Stage 2 Stage 3
Airway Normal Apnoea CPAP Cor pulmonale
BMI <35 35-50 50-60 >60
CVD <10% >20% IHD CCF
Diabetes Normal IFG/IGT Controlled Uncontrolled
Economic No impact disadvantage unemployed
Function Normal limited 3rd
party House-bound
Gonadal Normal PCOS Subfertile Breakdown
Health status Normal Low mood Depression Disorder
Image Normal impaired dysphoria Disorder

20. Airway
Basdevant et al. Obes Surg. 2007
0
20
40
60
80
100
%improvement
Banding Bypass

21. Control +1.6%Control +1.6%
Banding -13.2%Banding -13.2%
VBG -16.5%VBG -16.5%
Bypass -25%Bypass -25%
Weight loss at 10 yrs:Weight loss at 10 yrs:5
0
-5
-10
-15
-20
-25
-30
-35
-40
-45
0 0.5 1 2 3 4 6 8 10
Years of follow-up
Weightchange(%)Weightchange(%)
Body mass index
Sjöström L. et al N Engl J Med 2004

22. Cardiovascular disease
Diet/Drug induced weight loss NO mortality benefit (yet)
Sjostrom NEJM
2007

23. Diabetes

24. Hawkins S, Welbourn R et al Obes Surg May 2007
Economic
0
10
20
30
40
50
60
70
80
% in paid work Mean hours worked
Before surgery
After surgery
Population average
****
******
59 patients SW England
Jan 04 – Aug 06
14 months FU (3-32)

25. Functional
0
20
40
60
80
100
%improvement
Banding Bypass
Basdevant et al. Obes Surg. 2007

26. 12 patients: 100% resolution of menstrual abnormalities
Normalisation of sex hormones and SHBG
Significant improvements in hirsutism
Moreale et al, JCEM 2005
Gonadal

27. Heath status perceived (Quality of Life)
Karlsson et al. Int J Obes. 2007
50
30
10
-10
Health
perception
Social
interaction
Obesity related
problems
Depression
%improvement

28. Image
Returns to same levels as rest of population

30. Conclusions
Health care professionals – morbidity & mortality
Companies - productivity
Governments – healthcare costs
Patients - discrimination

31. Acknowledgements
Wellcome Trust
NIHR
University College Dublin
Prof Donal O’Shea
Prof Catherine Godson
Imperial College London
Prof Steve Bloom
Prof Mohammad Ghatei
University of Gothenburg
Dr Malin Werling
Dr Torsten Olbers
King’s College London
Dr Simon Aylwin
Prof Stephanie Amiel
Mr Ameet Patel
Musgrove Hospital, Taunton
Mr Richard Welbourn
Mr Dimitri Pournaras
University of Zurich
Dr Marco Bueter
Prof Thomas Lutz
University of Florida
Prof Alan Spector

32. 10
15
20
25
30
35
40
45
50
0
5
1 2 3 4 5 6 7
2nd centile
50th centile
98th centile
Age (years)
Child B
Response to leptin therapy in a child with
congenital leptin deficiency
Males
Weight (kg)
Courtesy Prof Steve O’Rahilly