Post on 18-Dec-2014
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How to stage patients with obesity
Carel le Roux
Diabetes Complications Research Centre
University College
Dublin,
University of
Gothenburg
Morbid obesity vs Obese morbidity
Sharma et al CMAJ 2011
Do you want to Medicalise this man?
Physically active
Happy
Employed
120/78 mmHg
Normal glucose and lipids
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 ?
Recidivism after volitional weight loss
BMI
Time
40
30
20
Volitional / pharmacological weight loss
Homeostatic response promotes
weight regain
Settling point
Reduced-obese state
Weight Management vs Obese Morbidity
Clinic Treatmentkg
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?
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
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
nt
abse
nt
abse
nt
pre-
clini
cal
risk
fact
ors
mild
mild
co-morbidity
moderate
moderateend-organ
damage
severesevere
end-stage
end-stage
end-stage
Obesity
www.drsharma.ca
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 2Diabetes
Stage 3Micro-/macro-vascular
disease
Stage 4BlindnessESRD
Type 2 Diabetes
www.drsharma.ca
EOSS Predicts Mortality in NHANES III
Padwal R, Sharma AM et al. CMAJ 2011www.drsharma.ca
EOSS Predicts Mortality at Every Level of BMINHANES III
Padwal R, Sharma AM et al. CMAJ 2011
Overweight
www.drsharma.ca
EOSS Distribution Across BMI CategoriesNHANES III (1988-1994)
Overweight
ClassIII
Padwal R, Sharma AM et al. CMAJ 2011
50 million
23 million
10 million
6 million
www.drsharma.ca
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
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
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
www.drsharma.ca
Key Points: EOSS provides
framework for clinical prioritization
predictor of obesity risk
Basis for management strategies
www.drsharma.ca
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
Airway
Basdevant et al. Obes Surg. 2007
0
20
40
60
80
100
% im
pro
vem
ent
Banding Bypass
Control +1.6% Control +1.6%
Banding -13.2%Banding -13.2% 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
5
0
-5
-10
-15
-20
-25
-30
-35
-40
-45
0 0.5 1 2 3 4 6 8 10 0 0.5 1 2 3 4 6 8 10Years of follow-upYears of follow-up
Weig
ht
ch
an
ge (
%)
Weig
ht
ch
an
ge (
%)
Weig
ht
ch
an
ge (
%)
Weig
ht
ch
an
ge (
%)
Body mass index
Sjöström L. et al N Engl J Med 2004
Cardiovascular disease
Diet/Drug induced weight loss NO mortality benefit (yet)
Sjostrom NEJM 2007
Diabetes
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)
Functional
0
20
40
60
80
100
% im
pro
vem
ent
Banding BypassBasdevant et al. Obes Surg. 2007
12 patients: 100% resolution of menstrual abnormalities Normalisation of sex hormones and SHBG Significant improvements in hirsutism
Moreale et al, JCEM 2005
Gonadal
Heath status perceived (Quality of Life)
Karlsson et al. Int J Obes. 2007
50
30
10
-10Health perception
Social interaction
Obesity related problems
Depression
% i
mp
rove
men
t
Image
Returns to same levels as rest of population
Conclusions
Health care professionals – morbidity & mortality Companies - productivity Governments – healthcare costs Patients - discrimination
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
10
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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
MalesWeight (kg)
Courtesy Prof Steve O’Rahilly