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severity of adiposity-related cardiometabolic risk is categorized into 4 levels independent of BMI: Stage 0 = metabolically healthy Stage 1 = one or two metabolic syndrome risk factors (waist circumference, elevated blood pressure, triglycerides, or low HDL-C) Stage 2 = impaired fasting glucose (IFG), glucose tolerance (IGT), or metabolic syndrome Stage 3 = two of three (IFG, IGT, and/or metabolic syndrome) Stage 4 = type 2 diabetes or cardiovascular disease 7 Bone and Joint Health Strategic Clinical Network but hidden by BMI. This includes those with a normal BMI (under 25 kg/m2 ) but adiposityrelated disease due to greater visceral fat, and those with sarcopenic obesity (who have clinically significant decreases in muscle mass that is hidden by higher adiposity)25 . Several clinical staging systems and assessment models have been developed that utilize a complications-based approach for adiposity-related health (Table 1). These models assist in identifying those individuals who would most benefit from intervention, ensuring limited health care resources are used wisely and focused appropriately, while minimizing the risk of treating healthy individuals and potentially worsening their health with misguided weight loss or unnecessary medications20 . Treatment of obesity Obesity treatment strategies for adults can be divided into three categories: 1) lifestyle interventions (utilizing a combination of diet, physical activity, sleep, and psychosocial support), 2) pharmacological (with only two medications currently approved in Canada), and 3) bariatric surgery. While lifestyle treatment is the cornerstone of obesity management, long term weight loss is difficult to maintain using lifestyle change alone due to strong hormonal and biological adaptation systems designed to preserve body weight26. As new medications are being developed, improved long term weight loss may be achieved using multimodal approaches that combine lifestyle and pharmacologic treatments. Currently, bariatric surgery is considered the most effective treatment for long term weight loss in adults with a BMI greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with significant comorbidity. Unfortunately capacity for bariatric surgery is limited. The 2017 Report Card on Access To Obesity Treatment in Canada27 highlights that less than 1 in 303 Albertans who need bariatric surgery will have access to it. Additionally, the wait time from referral to surgery in Alberta can take more than 2.5 years27 . Weight bias can inadvertently affect clinical treatment if persons with obesity are viewed as being non-compliant or lacking in self-control or motivation28. Obesity has been associated with beliefs that weight is all under the individuals’ personal control, and if they were motivated or had willpower they could manage their obesity29. These beliefs and biases are inaccurate and can create stigma for patients. Understanding the limitations of current obesity treatment strategies, and the biological and genetic factors that influence body weight regulation, will assist practitioners in engaging thoughtfully with patients to help them manage their osteoarthritis and obesity. Osteoarthritis and obesity Obesity contributes to osteoarthritis development and progression through multiple pathways, including increased biomechanical joint load, adiposity-related systemic inflammation, and associated metabolic influences 12 . Reciprocally, the pain and disability associated with osteoarthritis may influence obesity development or magnification5 . This interrelated cycle can have significant impacts, increasing the risk of accelerated osteoarthritis progression and 8 Bone and Joint Health Strategic Clinical Network leading to surgical management consideration at a younger age7 . Total joint arthroplasty (TJA) is most commonly performed in adults over 65 years old30 , but when patients have obesity surgery rates are highest in those age 45-647 . This need for earlier joint replacement can have important health and economic repercussions. The prosthetic components will likely require replacement within the individuals’ lifespan, often starting 10-15 years after the primary surgery31,32. Revision surgery is then required, which is a more complicated and lengthy procedure that can be limited by the quality and amount of bone available to hold new prosthetic components. There is a lack of information on how to slow the advanced progression of osteoarthritis in individuals with obesity. Obesity is commonly considered a “modifiable risk factor” for osteoarthritis10,33, and current clinical practice guidelines simply recommend weight loss for individuals who are overweight or have obesity13,34,35 . Specifically, recommendation for weight loss of 5-10% of body weight in 20 weeks are suggested to clinically reduce knee pain and disability (based on a meta-analysis of randomized controlled trials) 13,14,35,36. Yet this degree of weight loss may be difficult to achieve considering the limitations of lifestyle-based obesity treatments 18, particularly when patients don’t have the support and restriction of a controlled trial environment. These expectations can create frustration in both patients and healthcare practitioners when body weight does not change, but pain persists and physical function deteriorates, leading to significant challenges in determining best options for treatment. There is a need to identify and
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