I have to stop writing in about
5 20 minutes and get ready for work. So here goes:
Yesterday, two studies were released that had to do with using a different “staging system” to determine who, among people whose BMI put them in the obese category, was at greatest risk of death. Arya Sharma was a co-author in each of the studies. And the studies found that for people who had a BMI in the obese category, but who were “otherwise healthy” were not at substantially greater risk of death than people who were not in the obese BMI category. Yay! Someone finally found a way to control for ill heath concurrent with “obesity” when looking at risk of death.
Where I have an issue with the Edmonton Obesity Staging System (EOSS) is that it puts obesity, rather than anything else, at the center, as though obesity is the central health issue. If someone has diabetes and an “obese BMI” that does not make obesity the central issue. Most likely, the pathway to both high weight and diabetes had to do with a combination of genes, environment and “lifestyle.” So, addressing the “lifestyle” and to the extent possible, modifying the environment, while tailoring the treatment based on what is known about the genetic blueprint the person is working off of — that seems to me the best pathway. In other cases, the higher weight (possibly driven up by dieting) came before the other comorbidities, but it still doesn’t mean weight is the central issue.
What this system tries to do is to segment off those people who have a BMI in the obese category but few or no clinical markers of disease — and to say, the best thing to do for these people is to help them not gain more weight. Which sounds like HAES to me — HAES says, “dieting makes you fatter. Stop dieting. Live life fully. Eat well. Move joyfully. Be whole.” But does that mean that HAES is “off limits” to people who DO have markers of disease — be that diabetes, or depression, or extreme isolation in response to fat hatred? I think it isn’t — I think that putting the person, and the whole picture of their life at the center — that’s where the healing comes in, and the treatment needs to emanate from.
Recently, as I’ve blogged, I went through a rather serious bout of depression. I did request from my doctor that when we looked at the treatments available, we look for ones that wouldn’t lead to weight gain. If my doctor had said that he felt the very best treatment for me is usually associated with a 10 pound weight gain on average, I would have trusted him, and gone with it. That wasn’t what happened in my case, but if it had, I would have know he was looking out for me overall, not only my weight.
Another finding of one of the studies, because the self-reported lifestyle factors were collected, was that a healthy lifestyle helps regardless of weight status. Which is what we have been saying, those of us in the HAES camp, and I think this is an important message. Not a “you must do this or you aren’t worthy of treatment, compassion or human companionship” message — that’s bullshit. But, the message that people who are larger can live what is considered a “healthy lifestyle” — be as healthy (or close to as healthy) as their slimmer counterparts — and not end up any (or much) thinner.
Here’s a quote from Dr. Yoni Freedhoff about the studies:
These results are extremely important in that the EOSS is able to identify folks who are more likely to benefit from treatment. The flip side of that coin is that the EOSS is also able to identify folks whose doctors can stop lecturing them to lose weight, as at least from a mortality and cardiovascular disease perspective, EOSS 0/1 folks don’t seem to have any increased risks.
[Important to note here, the second study did find that cancer risk was elevated regardless of EOSS stage.]
These results are especially important for countries like Canada where fiscal restraints and socialized medicine means that there is far more demand than supply for bariatric surgery. The EOSS may help to appropriately triage those folks who are most in need of urgent care.
These studies also validate what I think most folks know to be true. Healthy lifestyles minimize weight related risks even in the absence of a so-called healthy body weight.
I hate it (HATE IT) when people make statements like “if you were living a healthy lifestyle, you would lose weight.” And I think these studies are fodder to fight that statement, and statements like it. I also think these studies are excellent ammunition against weight-loss-for-profit entities. “Lose weight to look more acceptable” — that’s an accurate statement. “Lose weight to be healthy” — isn’t. And if those people who benefit most, health-wise, from weighing less (not that we have healthy, sustainable ways to manage that in the population as a whole), those people are the ones receiving treatment for other health conditions in medical, or health-focused, settings (not that there aren’t plenty of snake-oil “medical” solutions out there).
However, for the vast majority of obese individuals, lifestyle-based weight loss is not maintained over the long term (Wing et al. 1995). This is particularly concerning, given that weight cycling is associated with greater weight gain over time (Van Wye et al. 2007) and potentially worse health outcomes, compared with individuals who may have maintained a stable body weight (Blair et al. 1993; Wannamethee et al. 2002). Although we observed that greater reported weight loss was associated with worse EOSS scores, it is unclear whether individuals with more severe EOSS staging had attempted to lose more weight because of their poor health, or whether they had poorer health because they had weight cycled. Furthermore, it is unclear whether obese individuals without existing comorbidities will develop metabolic abnormalities if they remain at a stable BMI; the literature is currently divided over the importance of obesity duration on metabolic risk. It has been proposed that the length of obesity predicts metabolic aberrations, and that adequate time is needed for metabolic abnormalities to develop in response to an obese state (Janssen et al. 2004; Wannamethee and Shaper 1999). Somewhat paradoxically, results from our study and other studies (Brochu et al. 2001) suggest that higher body weights earlier in life are associated with lower EOSS stages. Though speculative, it may be that individuals who develop obesity earlier in life exhibit an adaptive capacity, or perhaps these individuals are naturally predisposed to higher body weights because of higher insulin sensitivity — a factor associated with greater weight gain (Swinburn et al. 1991). Nevertheless, these factors, together, indicate that obese patients, particularly in EOSS stages 0 and 1, may be better served if physicians promoted weight maintenance, as opposed to weight loss, as it remains to be seen whether individuals in EOSS stages 2 and 3 will benefit from weight loss.
Okay, care to discuss? I’ll be back.