Clinical obesity, not morbid: A plea to change the diagnosis

Michelle Obama refers to childhood obesity as the tobacco of the 21st century. I agree. Obesity is quickly overtaking smoking as the nation’s No. 1 killer.

As a pediatrician who sees firsthand the impact of overweight and obese children, we need to have conversations with our patient families that focus on obesity as a clinical issue.

Right now, this isn’t happening. The rate of missed diagnosis for childhood obesity is over 95 percent, according to research my colleagues and I conducted at Akron Children’s Hospital in Akron, Ohio. Similar rates of under-diagnosis and under-documentation have been reported in other states.

Lack of obesity diagnosis

A few years ago during a medical hand-off of an ICU patient, a colleague described a 10-year-old patient as “a little under-grown.” Before I went in to see him, I checked his medical record and found that his BMI placed him at the 50th percentile. He was the definition of normal weight.

Intrigued by this, my colleagues and I launched a series of studies aimed at defining the actual and perceived burden of morbid obesity in our pediatric population.

Chart reviews revealed that nearly 14 percent of our patients met CDC criteria for obesity — their BMI was greater than 95 percent of children their age — yet clinicians only documented this 4 percent of the time. That means we failed to document (and presumably address) this life-changing diagnosis almost every time.

We speculated that maybe it’s because obesity isn’t a priority in the PICU because we’re just trying to save lives.

So we took our hypothesis to the primary care setting. After calculating BMIs for 63,500 children based on well-child visits, we found 14 percent of the children met the criteria for obesity. Yet, pediatricians documented their obesity only 3 percent of the time.

Numerous euphemistic diagnostic codes inferred, but never named, obesity as the diagnosis. This is akin to charting tuberculosis as an “unspecified bacterial infection.”

So, why are pediatricians not diagnosing obesity?

We found that a primary reason pediatricians fail to diagnose obesity is that they liken telling families their children are obese to delivering bad news.

Clinical vs. morbid obesity

In my opinion, our national care failure around pediatric obesity is because we’re reluctant to tell children and their parents that the Emperor is butt naked. Yes, your child does look fat in those jeans.

However, the discussion about weight is hardly cosmetic. If a child’s BMI is greater than 95 percent of his age-gender matched peers, there’s a promise of premature, preventable disability and death.

Yes, the bad news about an obesity diagnosis is a hard pill to swallow. But the good news about childhood obesity is that it’s a disease of childhood. There’s still time to move the conversation toward successful, life-changing interventions.

First, change the name of the diagnosis from morbid obesity to clinical obesity. Morbid obesity is, well, morbid or “gross.” Clinical obesity frames the conversation as categorically clinical, not cosmetic. Tell your patients and their families that clinical obesity is a threat to their health and welfare.

Then, tell them the good news. They are young, still healthy, and have a terrific opportunity to take charge of their lives by taking charge of their health.

Let’s have the clinical discussion — and don’t be gross.

Michael Forbes is a pediatric critical care physician, Akron Children’s Hospital, Akron, OH.

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