Writing / Obesity medicine in India
Stage before you prescribe: why I use EOSS, not BMI alone
BMI tells you how big a patient is. It does not tell you how much the weight is harming them.
BMI is a good screening number and a poor treatment decision. Two patients with the same BMI can be in completely different places: one with normal sugar, blood pressure and sleep, the other with type 2 diabetes, sleep apnoea and knee pain that has stopped them walking. Treating them alike because the number is alike makes no sense.
I prescribe anti-obesity medicine only when the Edmonton Obesity Staging System (EOSS) says it is indicated. This note explains why.
The five stages
| Stage | What it means |
|---|---|
| 0 | No obesity-related risk factors, symptoms or limitation. |
| 1 | Subclinical risk factors (borderline blood pressure, impaired fasting glucose, raised liver enzymes), mild physical symptoms, mild psychological symptoms or mild limitation. |
| 2 | Established obesity-related disease: type 2 diabetes, hypertension, sleep apnoea, osteoarthritis, PCOS, reflux, or an anxiety or mood disorder. Moderate limitation of daily life. |
| 3 | End-organ damage: myocardial infarction, heart failure, diabetic complications, or significant psychological or functional limitation. |
| 4 | Severe, potentially end-stage disability from obesity-related disease. |
Sharma and Kushner proposed the system in 2009. In later analyses of large population cohorts, EOSS stage predicted mortality independently of BMI. The Canadian adult obesity guideline of 2020 endorses it as a tool to guide clinical decisions.
Why it matters more in India
Indians develop diabetes, fatty liver and dyslipidaemia at lower BMIs than Western populations. That is why Indian cut-offs are lower. The 2009 consensus used 23 for overweight and 25 for obesity, and the 2025 Indian definition goes further, calling a BMI above 23 obesity and staging it by whether there is abdominal adiposity and an obesity-related complication. Its logic is close to EOSS. It also means BMI alone under-calls risk in a thin-fat patient and over-calls it in a large, metabolically healthy one.
Staging fixes both errors. A patient with a BMI of 27 and stage 2 disease is a more urgent case than one with a BMI of 31 at stage 0, and the treatment conversation should reflect that.
What staging takes in clinic
About five minutes, using what is already in front of you: history, blood pressure, fasting sugar or HbA1c, lipids, liver enzymes, a question about snoring and daytime sleepiness, a question about joints, a question about mood, and a question about what the patient can no longer do. No special equipment is needed.
What staging changes
- It moves the conversation from weight to health, which most patients find more motivating and less shaming.
- It gives a defensible reason for medicine in one patient and lifestyle first in another, which matters when the patient is paying.
- It sets a goal that is not a number on the scale: the stage coming down, a comorbidity going into remission, a limitation lifting.
Its limits
EOSS asks for clinical judgement at the boundary between stages, and two doctors can stage the same patient differently. Indian validation data are still limited. It is a framework for deciding, not a calculator that decides for you.
A free EOSS calculator, which colleagues and patients can use, is at caspianhealthcare.in/tools/eoss. Staging also decides the first question in how I weigh affordability.