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ICD-9 278



Yesterday, I chaired a round table organised by the Canadian Obesity Network on behalf of the Public Health Agency of Canada on the development of tools and aids that would help Canadian primary care physicians and other health professionals improve their ability to prevent and treat obesity.

Among the many topics discussed, one of the suggestions that found the most support was to encourage physicians to actually note the diagnosis of “obesity” in their charts. As many readers may know, obesity has long been considered a disease by the World Health Organisation and in fact has its own code in the International Classification of Diseases 9 system (ICD9): 278.

(Just to confuse things, the numbers for obesity in ICD 10 are E65-E68)

The idea here is that unless physicians actually begin recording the diagnosis of “obesity” in their notes, charts and other records, they will not address obesity with the attention it deserves.

Thus, as one attendee commented, “No doctor would ever dream of leaving out a mention of diabetes, hypertension, COPD or any other disease in their notes, but hardly any physcian ever records the diagnosis of obesity in their charts”.

Simply put, when physicians examine a patient who has obesity and fail to put down “obesity” in their medical chart, they are in fact committing an important breach in their obligations to correctly document their patient’s health status. This would in no way be different from failing to note the presence of diabetes, hypertension, or any other medical diagnosis in their records.

By failing to routinely document the medical diagnosis “obesity” in their records, the physicians are not only commiting an important error of ommission, they are, by the same token, actively ignoring one of the most important and common medical health problems in their patients.

Encouraging, or in fact, requiring physicians to actually note the diagnosis of “obesity” (ICD 278) in their medical records for all patients who meet the WHO criteria for obesity, would not only ensure a proper documentation of their patient’s medical problems, it would also (hopefully) increase the likelihood that they will address this issue with their patients.

I wonder how many of my health professional readers routinely note the diagnosis of “obesity” (ICD-9 278) in their charts when they see it in their patients and I wonder how many patients with excess weight have actually seen their physician record this diagnosis in their chart.

I am often reminded by patients when I ocassionally fail to list one of their many medical conditions in my notes or letters – interestingly, no patient has ever pointed out that I have missed the mention of their diagnosis “obesity” in my letters – I wonder why!

AMS
Edmonton, Alberta

9 Comments

  1. But why would you need to note that a patient has “obesity” if you already have their height and weight in the chart? I still disagree strongly with the assertion that obesity is a disease. Obesity seems more to be a symptom of various factors, but in and of itself does not exhibit a pathology.

    It seems like monitoring weight is one thing, but labeling patients “obese” does not seem to provide any benefits. According to your previous writings, your goal as a physician is to maintain that person’s weight long term. Permanent weight loss averages 10% of a person’s weight, so in most cases no improvement can be made to the actual obese status.

    Can’t we treat obese patients without taking the extra step of segregating them further in the medical community?

    Peace,
    Shannon

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  2. I am interested to see that the public health agency of Canada is working with CON to develop tools for use by family physicians and other health professionals to prevent obesity. In my opinion, tools for physicians to prevent obesity is focusing effort on the wrong end of the continuum. The myriad of reaons why people are obese have very little to do with doctors not having adequately tools. Furthermore, the effectiveness of what doctors can offer their patients in limited time office visits and the effectiveness of weight management strategies overall makes me question why place the focus there at all. If we were to place our resources on the upstream CAUSES of obesity verus the downstream EFFECTS we would, in my opinion, be much more likely to be successful. If we could address the societal factors which have resulted in this perfect storm culminating in a virtual epidemic over a couple of generations, that, I think, would be appropriate. Doctors making a note in a chart indicating their patient is obese suggests again, that the idea of personal responsibility is trumping the environment in which that obese person lives. A recent article by Kelly Brownell, et al discusses personal responsibility and I believe that the focus on downstream causes deflects attention from the upstream factors creating this perfect storm.
    ( http://content.healthaffairs.org/cgi/content/abstract/29/3/379 )
    Personal responsibility and obesity: A constructive approach to a controversial issue.

    The accompanying article by Thomas Frieden entitled “Reducing Childhood obesity through policy change: Acting now to prevent Obesity” suggests that the most effective ways to address obesity is to address socioeconomic factors such as poverty and education. The next greatest potential for impact is through changes in the social and physical environments that make people’s default choices healthy ones. Clinical interventions against obesity will have limited population impact and education and counselling will have the smallest potential impact.” Although I believe that our doctors need to be well versed in obesity and indeed note it in their charts, I don’t think it will make a big difference in the rates of obesity, or that is the biggest bang for our buck. I even wonder whether it is the appropriate place to spend the buck there given that the pot has limited bucks in it and our goal should be to have the biggest, longest term impact. I would advocate for changes that would make differences upstream and we stop blaming the victim. We need societal changes and “engagement in sectors beyond public health – most notably, education, transportation and agriculture – will be important to long term success”. I would like to see doctors involved in these upstream causes of obesity advocating for necessary changes. Perhaps what we really need is to spend our money on both aspects of this problem right now- downstream and upstream forces- versus pitting one against the other. If we only have a limited pot, however, where should we focus our efforts?

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  3. Shannon:

    The reason it is not enough to simply record hieght and weight, is because height and weight is not a “diagnosis”.

    It is not medical practice to simply record blood sugar levels and then nowhere in the chart also mention the diagnosis “diabetes” or to simply record blood pressure levels and not mention the diagnosis “hypertesion” if either of these values meet the criteria for these conditions.

    Not specifying the diagnosis has all knds of implications not least for the attention that is given to the problem, the treatment plan that is developed and the reimbursement and billing codes for the physician. There may also be legal implications for not keeping accurate medical records.

    Not specifying the diagnosis also has important implications for medical surveillance and statistics, which will report “diagnoses” but not actual measurements.

    So for e.g. to answer the question “how many patients with obesity are there in your practice?” Without stating the diagnosis, the answer may be “zero”.

    I agree that labels should not be judgemental – it is just stating the facts and ensure the accuracy of medical records.

    Also, what is done with the diagnosis in terms of treatment will (and should) vary with the degree and stage of obesity (as outlined inprevious posts).

    None of this speaks against the need to spell out the diagnosis in medical records – once again, there is nothing special about obesity!

    AMS

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  4. In the book “French Women Don’t Get Fat” the author tells of returning from a school year in the US 20 lbs overweight – her father was horrified, her mother was concerned. When she continued to gain, the family physician was called. (His treatment program was successful.)

    What is significant to me is that this was recognized as a problem when the author was just overweight. France has been admired for having less of a weight problem than here , and I think one of the reasons why is because being overweight is regarded as a real problem. It is not socially accepted. Family physicians are called.

    Not only is it good to write down “obesity” in a patients chart, it would be good to write down “overweight”. An overweight patient should get warnings about the danger of moving into obesity – especially that weight, once gained, is a permanent problem.

    I bet patients on the borderline for high blood pressure or diabetes or other conditions are warned by their doctors of their conditions, and given plans to avoid becoming sick.
    Are borderline conditions noted on charts? For example pre-diabetes, or borderline hypertension? Do doctors follow up on these conditions to make sure they don’t become serious?

    Overweight needs to be treated the same way. If patients are overweight, they need to know BEFORE they become obese that they are in danger. People also need to know that obesity is more than just a bit more fat to lose.

    The popular idea is that you gain weight, you lose weight – doctors should tell overweight patients that the next few pounds they gain won’t be just more of the same, the body will be damaged by obesity in ways that will make it difficult – if not impossible – to lose the extra weight.

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  5. I think there is far too little work done by medical professionals to treat the underlying causes of obesity. In the U.S., it is impossible to get any thyroid supplements even if you have ALL the symptoms of hypothyroidism and have for decades if your blood tests are “in the normal range.” I found out last summer that I have had Sjogren’s Syndrome all my life, and started getting fatigue in my late 20s. Nobody bothers to look at the underlying cause of the fatigue; they just blame it on overweight. Lyme disease is underdiagnosed because the blood tests for it are little better than a crapshoot. A positive is positive, but the false negative rate is about 80%. Polycystic ovarian syndrome wasn’t diagnosed in me until I was in my 30s.

    Had anyone bothered to look at underlying causes of my problems, or if I could perhaps find someone willing to treat me, not my blood tests, I think I could be in much better shape. I am very tired of the victims with excess weight being told how irresponsible they are and how much they deserve their suffering because they are costing everyone else unnecessary medical costs!

    This gets me to my problem with the diagnosis of “obesity.” You are simply labeling a symptom, not the underlying problem.

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  6. I’m 54 now, by the way.

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  7. Very thoughtful responses by all these five so far……..if the cause is depression and depression’s medication regime or it’s cause is abuse or trauma………it doesn’t describe the anticipated confounding effects of organ damage that we all work to try to minimize. I’m for calling a spade a spade, and sensitively helping the person turn around all the symptoms and signs that are obvious, as well as the underlying causes (perhaps hidden issues or diagnoses) that would remain or be troublesome in spite of weight loss efforts. Yes, it is a big multifaceted effort needed over time to save lives.

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  8. I agree with Dr. Sharma, “hypertension” is not a disease, neither is hyperglycemia, hypoglycemia, sepsis etc. Obesity, like all of these other things is a sign / symptom of pathology – behavioural, metabolic, etc. It’s also a sign / symptom that warns of future complications. By including obesity in your “diagnoses” , like hypertension, hyperlipidemia, etc, you are listing an important, modifiable, treatable condition that should be reviewed at each visit, and addressed as appropriate.

    Hypetension has underlying causes, but will you look if you don’t seee it? Same goes for dyslipidemia, dysglycemia, depression….I could go on. I hope I’ve made my point and added strength to Dr. Sharmas.

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