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The Edmonton Staging System: Post 1, Basics.

Some of you may have heard of the Edmonton Obesity Staging System. It’s gotten nods from size acceptance activists on social media sites because with its Stage 0 classification, it acknowledges that it’s possible to be fat and healthy and at a point where losing weight my any means necessary may not be advisable.

This is actually not a new idea. American guidelines dating back to the 1990s say the same thing. The National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity In Adults, The Evidence Report, published in 1998, only advises weight loss counselling for people who have a Body Mass Index (BMI) greater than 30, two other risk factors, and a desire to lose weight (chart, page 20). I can remember how happy I was when it first came out. It gave me something I could cite when doctors tried to push weight loss programs on me, when I had no risk factors other than a high BMI and no interest in dieting.

What is the Edmonton Staging System?

The Edmonton Staging System is chiefly intended to be a tool for rationing health care services in Alberta’s Health Care Insurance Plan. That’s Alberta’s single payer public health care system established under the Canadian Health Act.

What kind of health care services will be rationed? That's the big question. The most obvious are expensive weight loss treatments that may have a high net cost to the health care system; weight loss surgery in particular. However, this is a question that I'll revisit.

Who Designed it?

The Edmonton Staging System was developed by Dr. Arya Sharma and his colleagues at The University of Alberta. Steven Blair has also been involved in the research for the Edmonton Staging System. Dr. Blair is well known in fat acceptance circles for having done groundbreaking research for the Cooper Institute for Aerobics Research in Dallas in the 1990s; research that strongly indicates that activity level is a more important variable in health and fitness than BMI.

Dr. Sharma is a bariatric specialist and the founder and Scientific Director of the Canadian Obesity Network. On his blog, he questions the common beliefs about eating, activity level and weight, referring to the ubiquitous advice to lose weight by "eating less, moving more" as "the Nightmare on ELMM Street." He acknowledges that weight loss dieting is usually ineffective and sometimes counterproductive, long-term. However, it's important to remember that his career and livelihood are based on the idea that fatness is a disease that needs a medical cure.

Dr. Sharma and Dr. Blair may be more rational and compassionate than most people in the anti-obesity establishment, but they are not fat acceptance advocates.

So Without Further Ado, Here It Is

Stage 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations or impairment of well-being.

Stage 1: Patient has one or more obesity-related sub-clinical risk factors (e.g., elevated blood pressure, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well-being.

Stage 2: Patient has one or more established obesity-related chronic diseases requiring medical treatment (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate functional limitations and/or moderate impairment of well-being.

Stage 3: Patient has clinically significant end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/or significant impairment of well-being.

Stage 4: Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations and/or severe impairment of well-being

A Few Thoughts

I'm not going to be one of the people cheerleading for this system. I have some serious reservations about the Edmonton Staging System's weight-centric view of health. It could easily be (mis)used to ration care for any type of condition that can be linked to weight, for anyone with a high BMI.

I think its use should be limited to weight loss treatments, and I think that Dr. Sharma and Dr. Blair are capable of much more insightful work. It's just a new format for a way of thinking that's been around for decades, and it reinforces the weight centred paradigm that's (ready?) epidemic in the medical establishment right now.

Next week, I'l post links to some studies that explain the reasoning behind the Edmonton Staging System and links to some posts that discuss how it can or should be used. I'll also look around for media coverage.

Weight Has Little Impact on IVF Outcomes | BELOVED FANTASY OF A BLISSFUL PAST

richie79's picture
November 10th, 2011 | Link | "Dr. Sharma is a bariatric

"Dr. Sharma is a bariatric specialist and the founder and Scientific Director of the Canadian Obesity Network. On his blog, he questions the common beliefs about eating, activity level and weight, referring to the ubiquitous advice to lose weight by "eating less, moving more" as "the Nightmare on ELMM Street." He acknowledges that weight loss dieting is usually ineffective, and sometimes counterproductive, long-term. However, it's important to remember that his career and livelihood are based on the idea that fatness is a disease that needs a medical cure"

I've noticed that this rejection of 'ELMM' is quite common amongst bariatric surgeons, who if you think about it have an interest in pointing out the flaws of other common weight-loss strategies as a means of convincing people / decision-makers that WLS is the only effective method of losing weight. As you point out, whilst they may concede that fat is not 'caused' by an unhealthy lifestyle but by genetic or metabolic factors, for these doctors to then take the next step in accepting it as a natural characteristic or variation as opposed to a disease requiring a 'cure' would undermine a model which has proved very lucrative for all involved.

I agree that whilst there could be potential benefits in using this system to moderate the current frenzy of weight-loss surgeries by rationing availability to those with co-morbidities (as opposed to 14-year olds in order to help them 'fit in' at school), the fact that it was created by members of the anti-obesity establishment means that it is far less likely to be used for this purpose than to deny fat people treatment or even make treatment conditional on first undergoing WLS, as is increasingly becoming the case in the NHS.

"What is right is not always popular and what is popular is not always right" - Albert Einstein

Meowzer November 10th, 2011 | Link | So lemme get this straight.

So lemme get this straight. If I'm fat and I have brain cooties, the brain cooties are assumed to be caused by my fat? And slimming down by any means necessary (including, one supposes, giving up those fattening brain drugs) will get rid of them? Yeah, not a fan. Also, my being fat didn't give me PCOS, it was the other way around. If this guy is supposed to be my ally, give me MeMe, at least with her I know where I stand.

vesta44's picture
November 10th, 2011 | Link | I've been following Dr

I've been following Dr Sharma's blog for a while now, and let me tell you, reading it gives me a bad case of WTF on a daily basis. Some days he actually makes sense, from a HAES point, and other days he comes off as totally clueless.
According to his staging system, I'm stage 2 (arthritis and mobility issues). He would recommend weight loss for me, or at least weight maintenance (the maintenance I'm doing fine with all by myself, thank you very much, don't need a doctor to tell me how to do that). The weight loss he would recommend is WLS and sorry, WLSurgeons have had their one chance to kill me, they aren't getting another one, and diets don't work so that option is out. As for treating my arthritis, unless he's planning on replacing my knees, that's not changing (and from what I understand, Canadian surgeons have a BMI limit on people whose knees they'll replace, I'm waaaaay over it). And those mobility issues that he would have treated - good luck on him finding another doctor who won't blame them on my weight and prescribe that Nightmare on ELMM Street (been there done that). So until he changes the attitudes of all the doctors who are going to be using this staging system, he's not helping fat people at all. He's still recommending weight loss for people who aren't to the point of being terminally ill from their "obesity", and those that are, well, make them as comfortable as possible until they die (palliative care).
He posts all these "reasons" that people are/get fat, and the research that is looking for solutions to those "reasons". What they all don't seem to understand is that there is a paramount reason people are fat and it's called diversity, and that diversity allows for the survival of the human race. Do away with it, and you're dooming humanity to extinction when the next global disaster happens.

WLS - Sorry, not my preferred way of dying. *glares at doctor recommending it*

richie79's picture
November 14th, 2011 | Link | It would be wise for her to

It would be wise for her to apologize and try to start fresh, because he is an influential person in global circles, and he's NOT our enemy.

He may not be as strident in his calls for 'WLS for all' as some of the other crusaders out there, but I can't accept anyone who not only recommends and promotes but actively profits from something I honestly consider one of humanity's worst inventions to be in any way an ally or on board with the ideas behind FA, and I don't think Linda Bacon should be expected to either. Ultimately, WLS is about getting rid of 'the problem' of fat people by making them thin, an outcome considered by its proponents to more than justify the collateral damage and destruction which results from the procedure. Rather I would like to see Linda (or better still, someone with an even more radical approach based on fat as an entirely natural, perfectly acceptable element of human diversity) become more influential and respected than Dr. Sharma, whose position still ultimately boils down to fat being something bad which merits an eliminative approach.

"What is right is not always popular and what is popular is not always right" - Albert Einstein

richie79's picture
November 18th, 2011 | Link | Debra, I may have

Debra, I may have unwittingly lumped him in with some of our prominent anti-obesity campaigners (most of whom also recommend and perform surgeries on both NHS and private paying patients) and for that, I sincerely apologise.

In fact I have read parts of his blog, however (and this may say more about my personality and standpoint) I took away from it the impression that whilst he doesn't entirely support the dominant 'blame the individual' approach, or some of the current methods, he nevertheless seems to believe that there are other structural reasons for 'obesity' (besides it being a natural human variation), which if 'addressed' would result in the desirable outcome of fewer fat people.

I'm afraid I don't have the mental energy to sift the work of someone who ultimately wants us gone for the odd semi-positive crumb; I'd rather spend what time I have read radical, uplifting, uncompromisingly size-positive stuff that reminds me how fat can be powerful and joyous and something to celebrate and revel in rather than a social or medical problem that demands thin 'experts' ride to the rescue and save us from ourselves.

I do agree with you that there are a tiny minority of fat people (most of whom seem to end up on those TV 'freakshows') whose day-to-day-lives are significantly limited by physical difficulties caused by their weight. However the restrictions which affect most fat people are deliberately imposed by a society which maintains that any form of accommodation would undermine the ultimate aim of encouraging / persuading / forcing them to lose weight and become thin.

In short, I don't want the future historians of a world without fat people to look back see WLS as a crude and heavyhanded but ultimately necessary step, long-since replaced by 'safer' or 'more efficient' methods', to our ultimate elimination. Instead I want my great-grandchildren children taught of a dark period now thankfully past when moral panic and junk science resulted in the unwarranted demonisation of a physical characteristic as natural and beautiful as variations in height, ability, skin colour, sexuality etc. If that makes me some sort of radical then so be it - I've never claimed otherwise.

"What is right is not always popular and what is popular is not always right" - Albert Einstein

DeeLeigh's picture
November 18th, 2011 | Link | Well said!

Well said!

BigLiberty's picture
November 12th, 2011 | Link | Wait, hold up. I don't know

Wait, hold up. I don't know much about the staging system or Canadian healthcare, but is this being proposed as a measure for rationing care to obese people? That is, if you're a 'good fatty' you're allowed your regular healthcare like everyone else but if you're a 'bad fatty' you've got to pay?

I suppose I'm rather confused. Is the staging system about clinical diagnoses and recommendations, or is it about rationing care? If it's the latter, this is extremely scary.

Meowzer, I noticed that one, too.

I think this staging system is crap. It's still filled with all the crap-tastic assumptions about weight that have been shown to be false again and again, and doesn't even give the slightest nod to the highly heritable nature of body weight, nor the high failure rate of diets (that is, not enough to make fat people thin, or even the average obese person overweight).

It seems like a way to push stomach amputation...or *force it*. "Diets don't work. Get WLS and we won't ration your care."

I noticed there's nothing about rationing care for thin diabetics, thin people with high cholesterol, thin heart catch my drift. So even if WLS doesn't 'reverse' the 'comorbidities,' you can avoid having your care rationed (i.e., having to pay or having to pay more) if you get your stomach amputated.

Ugh, ugh, ugh. This is scary shit. I hope I'm not the only one who's freaked out by this.

DeeLeigh's picture
November 13th, 2011 | Link | Its about rationing care.

Its about rationing care. The primary intention seems to be to limit access to state-funded weight loss surgery, not to push it. WLS is expensive both short and long term, and public health care systems are not going want widespread use of it. I can't disagree with that.

But if the rationing goes beyond weight loss treatments and into other areas that then yes, it becomes very scary.

BigLiberty's picture
November 13th, 2011 | Link | I see. That's better, then.

I see. That's better, then. I agree, I hope it would become a way to ration care otherwise. We all know how these health measures (cough, BMI, cough) can end up serving interests not in their original intent.

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