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components of the joint, including the bone, synovium, cartilage and muscle. Additionally, metabolic and inflammatory factors related to obesity and dyslipidemia (abnormal levels of cholesterol, triglycerides, and/or lipoproteins in the blood) contribute to joint changes10–12, resulting in progressive cartilage deterioration, subchondral bone changes, loss of joint space, boney growths (osteophytes), and loss of joint function6 . Patients present clinically with symptoms of joint stiffness, reduced range of motion, pain, activity limitations and associated disability. Treatment Osteoarthritis treatment is focused on pain reduction, improved mobility and function, and maintaining quality of life while slowing the progression of the disease13 . Treatment strategies are categorized into non-pharmacologic (i.e. exercise, therapeutic modalities, bracing and use of assistive mobility devices), pharmacologic (i.e. pain and anti-inflammatory medications), and surgical options (i.e. osteotomy to preserve the joint, or joint replacement)13,14. A combination of pharmacologic and non-pharmacologic methodologies is considered best practice for treatment of early stages of the disease, along with helping patients self-manage their condition. Patients who are overweight are recommended to lose weight to reduce the load on the joint14 . If the disease progresses and pain and disability are severe, surgical treatment options are considered. Obesity Definition Obesity is defined by the World Health Organization (WHO) as abnormal or excessive fat accumulation that may affect health15 . The development of obesity is influenced by diverse causes, including genetics, environmental, psychosocial, medications-related, and individual factors. Obesity is also associated with the development of metabolic and cardiovascular conditions, such as diabetes, high blood pressure, dyslipidemia, and metabolic syndrome. Further, obesity is not simply a lifestyle problem, and its multifactorial development and progression highlights the persistence of this condition. Obesity is commonly identified using body mass index (BMI), a ratio of weight to height (calculated as weight in kg/height in m2 ). A 6 Bone and Joint Health Strategic Clinical Network BMI of 24.9 kg/m2 or less is considered normal, a BMI 25-29.9 kg/m2 is considered overweight, and a BMI over 30 kg/m2 is considered obesity. Obesity is then further delineated into class I obesity (BMI 30-34.9 kg/m2 ), class II/moderate obesity (BMI 35-39.9 kg/m2 ), and class III/severe obesity (BMI ≥ 40 kg/m2 ). The term morbid obesity is also used to describe patients with class III or severe obesity16 . Obesity has also been identified using percent body fat, waist circumference, and waist-hip ratio, which consider the location of excess body fat and its impact on health risk (i.e. visceral fat, or fat stored in the abdomen, is associated with higher risk of diabetes, metabolic syndrome and fatty liver compared with subcutaneous fat). Obesity was recognized as a chronic disease by the American Medical Association in 201321 , and by the Canadian Medical Association in 201522, as it requires lifelong management similar to other chronic diseases. The benefits of this recognition include investment in the development of medications for obesity treatment (similar to those developed for diabetes and high blood pressure that are utilized alongside diet and exercise), and improvements in diagnostic methods to identify and treat those with the disease. This is necessary to help distinguish between individuals whose body fat is impacting their health, and those who are healthy but have a larger body size (those who are fat but fit)23 . The diagnosis of obesity needs to move away from an anthropometric definition (BMI-centred), to include assessment of multiple clinical factors, as with other disease diagnoses23 . This will discourage the use of BMI as an independent diagnostic tool, shifting towards a complications-centred approach24 . This shift may also help distinguish and identify individuals with health risk related to body composition Table 1. Medical staging models for adiposity-related health Method Description Edmonton Obesity Staging System (EOSS)16 Used alongside BMI to identify presence and severity of adiposity-related health problems: Stage 0 = no impairment Stage 1 = subclinical risk factors or mild impairment Stage 2 = presence of obesity-related chronic disease Stage 3 = established end-organ damage (i.e. heart attack, diabetic complications) Stage 4 = severe disability from obesity-related chronic disease(s) Adiposity-based Chronic Disease model (ABCD)17 A complications-centred model to guide treatment decisions for adiposity-related disease: Stage 0 = no identifiable adiposity-based complications Stage 1 = mild to moderate adiposity-based complications Stage 2 = severe adiposity-based complications King’s Obesity Staging Criteria18,19 Considers adiposity-related health impact in ten domains: Airways, Body mass index, Cardiovascular disease, Diabetes, Economic complications, Functional limitations, Gonadal (reproductive) axis, Health status (perceived), body Image, and Other medical complications, and scores them from 0-3: Stage 0 = normal health Stage 1 = at risk of disease Stage 2 = established disease Stage 3 = advanced disease Cardiometabolic Disease Staging (CMDS) system20 The stage and
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