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

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

MalesWeight (kg)

Courtesy Prof Steve O’Rahilly