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Dr. Coutinho: 
Hello. This is CME on ReachMD, and I'm Dr. Walmir Coutinho. Here with me today is Dr. Charles Vega.

Charles, let's talk about best practices in diagnosing obesity. What do providers need to do?

Dr. Vega: 
Well, that’s a great question. And unfortunately, we don't diagnose obesity enough. In the United States, for example, even though 40% of US adults have obesity, it's a much smaller percentage that actually have that on their chart, electronic or otherwise, as a diagnosis. And this is one of the most important chronic illnesses we face. So how do you go about making a diagnosis of obesity? Really, the standard in the United States is set around the body mass index, or BMI. But that's not a perfect measure, unfortunately, of adiposity and the type of overweight or obesity that actually leads to negative outcomes like diabetes, like heart disease, and cancer.

So really, BMI is meant as a population tool for measuring obesity. It's not as applicable to individuals. So really, when I see somebody in practice, I try to get another measure, particularly of visceral adiposity. And the one for me in my community health center that makes the most sense is a simple waist circumference. Waist circumference is something that can be followed over time. It's an objective measure of that visceral adiposity, which is really important in promoting illness.

If you have another test that's available for measuring the concentration of adipose tissue, a bioimpedance test, dual-energy X-ray absorptiometry, or DEXA, that's great. Not all of us have access to those. But you want to do something.

I think one thing that I would add when it comes to measuring central adiposity is that for folks with a very elevated waist circumference, and it's clear they have a lot of visceral adiposity, I don't try to measure waist circumference because it's physically really challenging and can be very distressing for the patient, especially if they're already experiencing some shame and guilt around obesity in the first place.

So now it's also very important to code for obesity, and your patients may object to that. I've heard that before, so I always tell a patient before I put obesity on their problem list, because that's something that they can see. And at the end of the day, they're going to get a printout of their visit; obesity is going to be in there. So what I tell patients is, obesity is a chronic disease. It's a health issue. It's an important health issue, and if we don't chart it, we can't do anything, really, about it. So we can't recommend specific diet plans; we can't send you to an extra help like a dietitian or a mental health specialist; we certainly can't prescribe medications for it. And so if we want to become proactive and treat it like the chronic disease it is – and I often will say and it's just like your chronic shoulder pain, your hypertension, or your migraine headaches – we need to have it on the chart as a diagnosis. And I think that usually wins the day, and I'm able to get the diagnosis on chart.

And we're going to discuss how we shouldn't be using terms such as morbid obesity. Really, that's gone out of favor because it can be, and understandably so, offensive to patients. So you want to code the right way. And I’ve figured out some tools that help me do that in my practice with my electronic health record.

Dr. Coutinho: 
Okay, that was very helpful. I think that one takeaway message that we could highlight now is, as Dr. Vega just explained, is that we need to consider BMI but also include other adiposity measures and other factors in obesity diagnosis to achieve a more comprehensive evaluation of the risks associated with obesity. Let's remember that overweight kills 5 million people every year, and 2 million out of these 5 have a BMI lower than 30, so we have to make sure that no one is left behind.

Thank you very much for your attention, and we hope you'll find this information useful in your practice. 

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