Documentation of overweight or obesity diagnosis codes during adult primary care encounters

Obesity is highly prevalent among U.S. adults and is associated with substantial morbidity and mortality. Primary care clinicians are well positioned to identify patients with overweight or obesity and address related health risks. Prior studies suggest that obesity is often underdiagnosed, but less is known about how frequently overweight or obesity diagnosis codes are documented during routine primary care encounters.

This was a retrospective observational study of 49,279 adult family medicine and internal medicine encounters at Mayo Clinic in Jacksonville, Florida, from July 1, 2021, through June 30, 2022. Encounters included adults ≥18 years of age with a recorded body mass index (BMI) ≥25 kg/m². The primary outcome was documentation of an overweight or obesity diagnosis code (OODC) during the encounter. Logistic regression evaluated associations between patient, clinician, and encounter characteristics and OODC documentation.

An OODC was documented in 3658 encounters (7.4%). Documentation increased across BMI categories, from 2.5% of encounters involving patients with overweight to 22.0% of encounters involving patients with class III obesity. In multivariable analysis, class III obesity had the strongest association with OODC documentation compared with overweight (adjusted odds ratio [aOR], 11.22; 95% confidence interval [CI], 10.05, 12.55). Male clinician sex was associated with modestly lower odds of documentation (aOR, 0.88; 95% CI, 0.81, 0.95). Internal medicine encounters had higher odds of documentation than family medicine encounters (aOR, 1.24; 95% CI, 1.14, 1.35), while office visits had lower odds than comprehensive visits (aOR, 0.70; 95% CI, 0.65, 0.75).

OODCs were infrequently documented during adult primary care encounters involving patients with BMI ≥25 kg/m². Documentation increased with BMI severity but remained uncommon overall and varied according to clinician age, clinician sex, department, and encounter type.