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Clinical Staging for Obesity
Raj Padwal
Clinical Pharmacology and General Internal Medicine
University of Alberta
Disclosures
Funding: CIHR, Heart and Stroke Foundation of Canada, University Hospital Foundation.
Research Collaboration: Novo Nordisk, CVRx
Speaking and other Honoraria: none
Key Points
1.
BMI is only an indirect measure of adipositya.
Good for epidemiological studies
b.
Limited use for measuring individual risk
2.
Comorbidity based classification systems offer improved predictive risk
a.
Complementary role anthromopetric indices
Body Mass Index
AdolpheQuetelet(1796‐1874)
‘Weight is more or less
height squared’
BMI and Mortality Risk
Gonzalez et al. NEJM 2010
19 prospective studies with nearly 1.5 million white adults.
BMI and Body Fat
DXA scan of two individuals with the same BMI but markedly different percent body fat
European South Asian
Yudkin & Yainik, Lancet 2004
Relationship Between BMI and Percent Body Fat in Men and Women
Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694.
Bod
y Fa
t (%
)
Body Mass Index (kg/m2)
0 10 30 40 6020 50
Women
Men
010203040506070
Health Hazards of Obesity
‘Know the grave doth gape
For thee thrice wider than
for other men’
Henry IV
William Shakespeare
(1564‐1616)
Adolf Schrodter: Falstaff and his page
9/33
Medical Complications of Obesity
Idiopathic Intracranial Hypertension Stroke
Cataracts
Accelerated AtherosclerosisCoronary Heart Disease
Diabetes
DyslipidemiaHypertension
Severe Pancreatitis
Cancer
Phlebitisvenous stasis
breast, uterus, cervix,colon, esophagus, pancreas,kidney, prostate
SkinGout
Osteoarthritis
Pulmonary Disease
Nonalcoholic Fatty Liver Disease
Gall Bladder Disease
Gynecologic Abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome
steatosissteatohypatitiscirrhosis
abnormal functionobstructive sleep apneahypoventilation syndrome
Source: CON
Comorbidity Based Classification
King’s Obesity Staging Criteria
Aasheim et al. ClinObes 2011
King’s Obesity Staging Criteria
144 patients beforeand one year afterbariatric surgery.
Aasheim et al. ClinObes 2011
Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
Med
ical
Men
tal
Func
tiona
l
abse
ntab
sent
abse
nt
pre-
clinic
al
risk f
actor
smild
mild
co-morbidity
moderate
moderateend-organ
damage
severesevere
end-stage
end-stageend-stage
Obesity
Objective
• To determine if the EOSS independently predicts mortality in a population‐based sample
Objectives
• Examined the association between EOSS and mortality in models adjusted for BMI and
metabolic syndrome as well as BMI and hypertriglyceridemic waist.
• Examined the predictive ability in subgroup eligible for bariatric surgery.
Methods
• Data source: NHANES III (1988‐94) (n=4367) and NHANES 1999‐2004 (n=3600; 3 2‐y cycles)
representative sample of the US non‐ institutionalized population
– Overweight and obese adults randomized to the Mobile Examination Center morning subsample
• Endpoint: mortality by linking to public use files in the National Death Index
• Follow‐up to end‐2006
Methods: EOSS AssignmentParameter EOSS 0 EOSS 1 EOSS 2 EOSS 3
Blood
pressureOptimal pre‐HTN HTN ‐
Cholesterol Optimal borderline high ‐
Glucose Optimal Pre‐diabetes DM ‐
Liver disease
(partly SR)Normal Elevated liver
EElevated liver
E and liver dz‐
OA (SR) None Joint pain in
past year but
no OA
OA ‐
Physical
health (SR)normal Physical
impairment
but no ADL
limit
ADL limit ‐
GFR ≥90 60‐89 30‐59 <30
Patients with CAD, CVD, CHF (all SR) assigned to EOSS 3.
EOSS and Mortality
EOSS and Mortality
EOSS and Mortality
EOSS and Mortality
EOSS and Mortality Within BMI Class
Overweight
EOSS and Mortality Within BMI Class
NHANES III Results (Cox Model)
Variable (Reference) HR (95% CI)
EOSS Stage (Stage 0/1)
EOSS Stage 2 1.6 (1.2‐2.1)
EOSS Stage 3 2.7 (2.0‐3.7)
BMI (Overweight)
Class I 1.2 (1.01‐1.5)
Class II 1.7 (1.2‐2.5)
Class III 1.5 (0.9‐2.5)
Metabolic Syndrome (absent)
1.1 (0.98‐1.3)
NHANES III Results (Cox Model)Variable (Reference) HR (95% CI)
EOSS Stage (Stage 0/1)
EOSS Stage 2 1.6 (1.2‐2.2)
EOSS Stage 3 2.8 (2.1‐3.7)
BMI (Overweight)
Class I 1.3 (1.03‐1.6)
Class II 1.8 (1.3‐2.6)
Class III 1.6 (1.02‐2.6)
Hypertrig
Waist (absent)
Age ≤
60 y 1.2 (0.7‐1.9)
Age 61‐81 0.9 (0.7‐1.1)
Age ≥
82 0.9 (0.7‐1.1)
NHANES III Results (Cox Model) Bariatric Surgery Eligible (n=546)
Variable (Reference) HR (95% CI)
EOSS Stage (Stage 0/1)
EOSS Stage 2 3.9 (0.8‐18.8)
EOSS Stage 3 12.3 (2.1‐72)
BMI (Class II)
Class III 0.9 (0.4‐2.0)
Metabolic Syndrome (absent)
1.3 (0.6‐3.1)
Limitations of Comorbidity Based Scores
• Requirement for detailed information– ? Simplified version
• Arbitrarily considered comorbidities as equivalent – e.g. diabetes and osteoarthritis
– ? Weighted version
Key Points
1.
BMI is only an indirect measure of adipositya.
Good for epidemiological studies
b.
Limited to measure individual risk
2.
Comorbidity based classification systems offer improved predictive risk
a.
Complementary role anthromopetric indices