Testing the Edmonton Obesity Staging System

EOSS Part 2

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In part 1 we talked about the Edmonton Ob*sity Staging System (EOSS) which was created by two “ob*sity medicine” doctors to pathologize fat people based on symptoms and health issues that thin people also get. Today we’ll look at a study that included one of those authors to test this system.

Quick Overview:

I’m going to do a deep dive into this study, but I’ll sum it up here. The authors of this study, who have pinned their careers to the body-size-as-disease paradigm never consider the idea that bodies should not be pathologized based on size. They utilized a staging system (well, a modified version of that staging system) created by a similar set of authors, that separates fat people into categories based on health issues, mental health, and dis/ability. While these are categories that literally any group of people could be separated into, if you’re fat and meet the criteria for these categories, the authors would have us believe that it is an indication that weight loss is “required.”

They offer no proof that long-term, significant weight loss would change people’s categorization within the system, improve their health, or reduce their mortality. And yet they continue to recommend it, despite their own admission that weight cycling is the primary outcome of weight loss attempts and that people who weight cycle are more likely to have the health issues that the EOSS uses to pathologize them.

Want to know more? Let’s dig in:

The authors:

Jennifer Kuk, the lead author is someone you may recognize as an author of a study that I use as an example of weight loss recommendations supported by misleading conclusions.

Steven Blair disclosed that he serves on the Jenny Craig, Technogym, and Alere Medical Advisory Boards, and has research grants from Body Media and Coca Cola. He is also an interesting case in that he is higher-weight himself and is often quoted in the media extolling the virtues of fitness regardless of weight/weight loss (though always from an anti-“ob*sity” platform.) In a 2019 interview he was asked

“You have been a great thinker who often challenged the beliefs and/or myths that had little scientific evidence. I heard that you recently argued that “the health risks of ob*sity have been exaggerated”. What are the main points that support your argument?”

He answered:

“We published our first paper on fitness and fatness in 1995 and have since published many papers on this topic. In the ACLS we have measures of CRF, body mass index, and body composition. A general summary is that ob*se individuals who are at least moderately fit, which can be achieved by meeting the PA guidelines, have one-half the risk of dying in the next several years when compared to normal-weight individuals who are unfit. I have been often criticized on this point, but my response is: do some research with good measurements of PA, ob*sity, and health outcomes, and show that we are wrong!”

Timothy Church disclosed that he serves on the Jenny Craig Medical Advisory Board.

The other authors claimed no conflicts of interest to declare, though I would point out that having a career invested in the anti-ob*sity industry isn’t considered a conflict of interest, even if the recommendations of a paper will directly benefit the authors financially.

Now, I don’t think any of these authors are being intentionally harmful, I think that they are fully committed to a body-size-as-disease/weight-loss-as-cure paradigm. I think that, a few decades ago, if you found a bunch of researchers who were just as invested in the “homosexuality” as disease model they may have created research very much like this.

The claims:

Body mass index (BMI) is the most widely used measure of adiposity, but variation exists in terms of the comorbidities present and the mortality risk observed at a given BMI (Brochu et al. 2001; Calle et al. 1999; Dvorak et al. 1999; Sims 2001). In light of this, it has been suggested that not all ob*se individuals are at increased health risk (Brochu et al. 2001; Dvorak et al. 1999; Sims 2001), and therefore may not require weight loss.

They offer no proof that “ob*sity” (however it is measured) is actually the cause of these disparities, nor any proof that the weight loss they suggest is “required” will actually have a positive effect. This mistake frequently makes it past peer review because the belief in it has reached “everybody knows” status, but (at least for me) in order to buy into the rest of this system those things would actually have to be proven true, and they are not.

They used data from “a cohort of participants who attended the Cooper Clinic (Dallas, Tex.) for periodic self- or physician-referred medical examinations between 1987 and 2001.” More than 99% of the study population was “non-Hispanic white, well educated, and of middle and higher socioeconomic status.”

How extrapolatable is this data if almost every single person had this much privilege? They actually had to modify their own system to accommodate this data.

EOSS level was categorized on the basis of the highest-stage risk factor present for each individual, according to the operational criteria defined in Table 1. For example, an individual with normal fasting glucose, normal lipids, no psychopathology, no functional limitations (stage 0), but with diagnosed hypertension (stage 2), would be categorized as EOSS stage 2. Similarly, an individual with borderline hypertension, impaired fasting glucose (stage 1), osteoarthritis, and anxiety disorder (stage 2) would also be categorized as EOSS stage 2.

So a fat person with normal fasting glucose, normal lipids, no psychopathology, no functional limitations, but with diagnosed hypertension (a profile that matches MANY thin people) becomes a fat person who “requires” weight loss. The many thin people with the exact same symptomology just need…methods to manage their blood pressure. This is an example of how people jump off the logic train before it reaches the station in order to justify the weight-centric paradigm.

Lifetime weight lost, preferred body weight, lowest adult body weight, and weight at age 21 years were predictive of EOSS stage 2 or 3 after adjustment for age, BMI, sex, smoking status, and exam year. Similarly, weight cycling, dieting, inadequate fruit and vegetable consumption, and low cardiorespiratory fitness were associated with prevalent EOSS stages 2 and 3

The fact that dieting itself and weight cycling (the outcome of almost every weight loss attempt,) are associated with having more health issues is not a glowing endorsement for the intentional weight loss attempts they recommend.

Also note that health-supporting behaviors, in this case fruit and vegetable consumption and cardiorespiratory fitness, were protective which is what plenty of research already told us.

This study clearly demonstrates that the EOSS can be used to help differentiate individuals at increased mortality risk. Independent of BMI, weight history and lifestyle factors were shown to influence the severity of EOSS and may, therefore, help physicians identify high-risk individuals who are most in need of weight-management interventions.

Wait, what? This seems to be not so much an endorsement of creating these “stages” of fatness in order to recommend the exact weight loss interventions that they have identified as putting people at greater risk for increased mortality (which, again, was known,) but, rather, an endorsement to move to a weight-neutral paradigm where people focus on health-supporting behaviors rather than manipulation of body size.

Overweight and ob*sity are associated with several metabolic aberrations that increase risk for CVD, CHD, type 2 diabetes, several cancers, and many other conditions (National Institutes of Health 2000).

Remember that “associated” means correlated which means that these things happen at the same time, but that the actual causal mechanism is not known. That’s why one of the foundational principles of research is that “correlation does not imply causation.” It’s not responsible not to make that clear, especially without explaining that weight stigma, weight cycling, and healthcare inequalities (all of which higher-weight people typically experience more than thin people) are also associated with these “metabolic aberrations.”

By the way, their citation for this claim is a document created in part by the North American Association of the Study of Ob*sity (an organization that represents the weight loss industry). The creation of the document was chaired by Xavier Pi-Sunyer, who was also chair of the NIH panel that lowered the classification of “overweight” to make about 29 million Americans “overweight” literally overnight while he was a former Executive Director and current member of the Board of Directors of the Weight Watchers foundation. He has also been a paid consultant for nearly every diet drug company that exists including the manufacturers of fen-Phen, Wyeth-Ayers. This led to him being sued for having articles that were written by a medical consulting firm (that Wyeth hired) attributed to him, one of which was subsequently published under peer review. Xavier Pi-Sunyer may get his own edition of this newsletter at some point but for now I’ll say that I don’t think any of his work can be taken at face value given his staggering conflicts of interest.

Although BMI is associated with increased mortality risk, there was considerable variation in the health risk profile observed in the ob*se population, and results from this analysis suggest that EOSS may be useful for clinicians in the identification of patients at higher mortality risk, beyond BMI alone. The finding that there were no differences in all-cause mortality risk between ob*se individuals in EOSS stage 0/1 and normal-weight individuals brings into question whether weight loss is beneficial for reducing health risk in this unique ob*se population.

There are a lot of questionable ideas stuffed into this paragraph, all of which serve to justify this weight-centric paradigm.

First, note the use of “associated” again.

Second, if you read closely what they actually found was that fat people who have health issues that are known to cause an increase in all-cause mortality have…an increase in all-cause mortality.

Their choice of calling those in “stage 0/1” a “unique population” is similarly ridiculous and only makes sense if you buy into the idea that weight is a proxy for health in the first place. One could say that thin people who fit into the “stage 0/1” classifications are similarly unique.  

Lifestyle behaviours clearly have an effect on health, and individuals in EOSS stages 2 and 3 were less likely to be dieting, to eat adequate fruits and vegetables, and to be previous smokers. Indeed, adjustment for fitness and dietary factors abolished many of the associations between EOSS and mortality. First, smoking is associated with a lower body weight and several deleterious health outcomes. Although smoking cessation is unlikely to be the direct cause of negative disease outcomes, it is often associated with weight gain (Reas et al. 2009). Second, higher EOSS stage was associated with lower minimum adult body weight, but similar maximum adult weights. Third, lifestyle factors, such as diet and physical activity, can influence health risk, independent of BMI (Yusuf et al. 2004), and form the foundation of weight management (National Institutes of Health 2000).

Again, this seems to be an endorsement for a weight-neutral health paradigm where the focus is on supporting health, not manipulating size. Of course, there’s the second part of the last sentence but note that they are, once again, citing that questionable paper and that while they can claim that lifestyle factors form “the foundation of weight management” when it comes to recommendations (though I would argue that they don’t, since the foundation of weight management is giving people’s bodies less fuel than they need in the hopes that they consume themselves and become smaller) what they can’t say is that they form the foundation of successful weight management, since a century of data tells us that these weight management recommendations will fail for the vast majority of people.

But don’t take my word for it, they admit it themselves:

However, for the vast majority of ob*se 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).

I’ll point out here that, in my experience, those who are involved in the weight loss industry tend to only be willing to admit the failure of behavior-based weight loss interventions when they are trying to promote more dangerous (and expensive) weight loss drugs and surgeries, and rarely/never point out that (understanding that health is not an obligation, barometer of worthiness, or entirely within our control,) a weight-neutral paradigm is a completely viable option.

Ob*sity in the absence of metabolic aberrations has been termed, in the literature, “metabolically normal but ob*se,” and it has been suggested that these individuals may not require weight loss per se

I don’t mean to belabor the point, but I feel compelled to point out, again, that all of this is based on the idea of first pathologizing bodies based on size. You could also divide thin people up into these same categories.

Indeed, the health risks associated with overweight and ob*sity are not limited to metabolic conditions, as ob*se individuals are more likely to be diagnosed with cancer at more advanced stages (Hahn et al. 2007) and to die from traumatic injuries (Viano et al. 2008) than their normal-weight counterparts. Further, the weight bias of some health professionals results in greater reluctance to provide health care, a problem that is compounded by the fact that ob*se individuals are more likely to avoid seeking health care (Puhl and Brownell 2001).

It is odd to me that they separated the information about late-stage cancer diagnoses and higher rates of traumatic injury deaths and the information about weight bias as if they are two separate things, without examining how the latter may impact the former. This is the kind of assumption, rooted in weight stigma, that doesn’t just get fat people killed, but blames us for our own deaths.

For example, research shows that higher-weight people are less likely to get early cancer screenings and weight stigma – including both practitioner bias and structural weight stigma. Lee and Pausé found:

Fat individuals are less likely to access healthcare, and are less likely to receive evidence-based and bias-free healthcare when they do engage. For example, fat ciswomen are less likely to receive cervical cancer screening, breast cancer screening, and colorectal cancer screening than non-fat ciswomen; this is especially true for super fat ciswomen.

When it comes to traumatic injuries, fat patients are at higher risk of having their care compromised by both practitioner bias and structural bias (wherein the tools, techniques, equipment, best practices, pharmacotherapies and more were developed for thin bodies.)

The idea that the negative impacts of these inequalities (which, as these authors astutely point out, include death) should be blamed on “ob*sity” (in other words, blamed on fat people for existing) is exactly the attitude which, intended or now, allows the system to continue to kill fat people with impunity.

In this study, cancer and non-CVD and noncancer causes of death were not associated with EOSS staging, and suggest that normal-weight and ob*se individuals are at a similar risk for these causes of death. However, further research is required to examine the factors within EOSS that are most predictive of mortality risk.

This is the last bit of the study and it really highlights the issue with the study. The idea that CVD death is associated with their made-up staging system ignores the fact the CVD death is also associated with weight cycling, the most likely outcome of undertaking a weight loss intervention – which is what is recommended to those at higher EOSS stages.

We don’t need special classification systems for higher-weight people that are built on correlations and ignore confounding variables. We need a healthcare system that is focused on providing excellent care to people of all sizes. It may not be as profitable as the weight loss paradigm, but it’s the right thing to do from both a research and social justice perspective.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.

Note I don’t link to everything I discuss in this post because I don’t want to give traffic and clicks to dangerous media.