Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Research article

Coding of obesity in administrative hospital discharge abstract data: accuracy and impact for future research studies

Billie-Jean Martin1*, Guanmin Chen1, Michelle Graham2 and Hude Quan1

Author Affiliations

1 Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Room C849, 8th Floor Cardiology, 1403 29th Street NW, Calgary, AB T2N 2 T9, Canada

2 Department of Medicine, University of Alberta, Edmonton, AB Canada

For all author emails, please log on.

BMC Health Services Research 2014, 14:70  doi:10.1186/1472-6963-14-70

The electronic version of this article is the complete one and can be found online at:

Received:27 February 2013
Accepted:5 February 2014
Published:13 February 2014

© 2014 Martin et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.



Obesity is a pervasive problem and a popular subject of academic assessment. The ability to take advantage of existing data, such as administrative databases, to study obesity is appealing. The objective of our study was to assess the validity of obesity coding in an administrative database and compare the association between obesity and outcomes in an administrative database versus registry.


This study was conducted using a coronary catheterization registry and an administrative database (Discharge Abstract Database (DAD)). A Body Mass Index (BMI) ≥30 kg/m2 within the registry defined obesity. In the DAD obesity was defined by diagnosis codes E65 – E68 (ICD-10). The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an obesity diagnosis in the DAD was determined using obesity diagnosis in the registry as the referent. The association between obesity and outcomes was assessed.


The study population of 17380 subjects was largely male (68.8%) with a mean BMI of 27.0 kg/m2. Obesity prevalence was lower in the DAD than registry (2.4% vs. 20.3%). A diagnosis of obesity in the DAD had a sensitivity 7.75%, specificity 98.98%, NPV 80.84% and PPV 65.94%. Obesity was associated with decreased risk of death or re-hospitalization, though non-significantly within the DAD. Obesity was significantly associated with an increased risk of cardiac procedure in both databases.


Overall, obesity was poorly coded in the DAD. However, when coded, it was coded accurately. Administrative databases are not an optimal datasource for obesity prevalence and incidence surveillance but could be used to define obese cohorts for follow-up.

Obesity; Coding; Administrative data; Clinical databases; ICD-10


Obesity is a highly prevalent health concern. While it is well established that many North Americans are obese, [1] similar trends are now being seen worldwide, even in countries such as India, where malnutrition was long the most common nutritional disorder. Obesity is now in line to overtake smoking as the leading preventable cause of morbidity and mortality, causing in excess of 300,000 deaths per year in the United States alone [2,3]. The burden of disease attributable to obesity is in large part due to its impact on the cardiovascular system of these individuals [4-6].

There are several published ways of measuring obesity, ranging from the simple, such as body mass index (BMI, kg/m2) or waist circumference, to the complex, including body densitometry and more advanced volumetric techniques such as computed tomography (CT) imaging and magnetic resonance imaging (MRI) [7,8]. While the latter methodologies offer more accurate measurements of body composition, the former are more widely employed due to their relatively low cost, ease of use and familiarity. They are, however, prone to bias: frequently measures of weight and height are taken based on self -report which is rather unreliable, as women tend to underreport weight and men to over report height.

Gathering information on the adiposity of a population is difficult and time consuming: national surveys such as NHANES are expensive, and international studies such as the International Day for the Evaluation of Abdominal Obesity (IDEA) are logistically challenging [9]. It is even more challenging for follow-up studies to collect longitudinal information on obesity and outcomes from a large population. Being able to take advantage of existing administrative data, such as physicians claim and hospital discharge databases, could be potentially time and cost saving because obesity is captured as a diagnosis by the International Classification of Disease (ICD), codes 278 (ICD-9-CM) and E65 – E68 (ICD-10). In many developed countries (such as Canada), there are massive national administrative databases that are easily linked with other databases for research purposes. However, even though BMI is easily derived from standard clinical information, administrative data frequently does not capture height and weight.

There has only been limited evaluation of how frequently obesity is actually captured in administrative databases, or how accurately it is captured. A study by Quan et al from 2003 assessed obesity coding as one of their outcomes [10]. Chart review demonstrated an 8.3% frequency of obesity – while ICD-9-CM data reflected a 2.7% (sensitivity 24.6% and positive predictive value (PPV) 75.9%) rate of obesity, and ICD-10 coding a 1.9% rate (sensitivity 18.6%, PPV83.8%). The association between coded obesity and adverse outcomes has not been well studied in administrative databases, such as those used in Canadian health care systems.

The objective of our study was to assess the validity of obesity coding in an administrative database. To conduct this study, we linked clinically captured physical measurement data, including height and weight, with administrative data to asses how frequently and accurately obesity is captured in an administrative database. To understand performance of obesity research using administrative data, we then determined the association between obesity and outcomes in an administrative database first and then replicate such analysis in registry. We evaluated if results generated from these two databases are comparable. This study will enrich the available information on obesity coding, and will allow the assessment of the utility of administrative data for population surveillance of obesity.


Defining obesity in physical measurement dataset

Our study was conducted using two data sources: The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database and the Inpatient Discharge Abstract Database for the Calgary health region.

APPROACH is a clinical registry which has captured detailed clinical information on all patients undergoing cardiac catheterization in Alberta, Canada since 1995 [11]. At the time of catheterization, data are collected on clinical risk factors including age, sex, weight, height, body mass index (BMI, kg/m2), hypertension, hyperlipidemia, diabetes, chronic lung disease, cerebrovascular disease, congestive heart failure, peripheral vascular disease, renal disease, liver or gastrointestinal disease, and malignancy. Also recorded are the results of coronary catheterization including coronary anatomy and left ventricular ejection fraction, procedures done at the time of initial catheterization and events thereafter (percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and death).

Obesity was defined within the APPROACH database using the Quetelet formula for BMI: weight (kilograms) divided by height (m) squared. A subject was determined to be obese in the APPROACH database if they had a BMI ≥ 30 kg/m2. Obesity classes were determined using the standard World Health Organization definitions: subjects with a BMI 30-34.99 kg/m2 were considered Obesity Class I, subjects with a BMI 35-39.99 kg/m2 were considered Obesity Class II, and subjects with a BMI ≥ 40 kg/m2 were considered Obesity Class III [12].

Defining obesity in the hospital discharge abstract database

The Inpatient Discharge Abstract Database (DAD) collects administrative information on date and time of admission, length of stay and up to 25 diagnoses. Using the DAD for the years 2002-2008, obesity was defined by searching the diagnosis codes E65 – E68 (ICD-10) in the 25 diagnosis coding fields.

The APPROACH database and DAD were linked using Personal Health Numbers (PHNs), which are unique to each individual. Patients were excluded if they were under 18 years of age, did not have a valid Alberta PHN, or were from outside the Calgary Health Region. As the clinical covariates used for the study were obtained from the APPROACH database, cohort entry date was defined as the date of coronary catheterization. Only subjects who had a hospitalization in the first 6 months following catheterization were considered in this study. The diagnosis of obesity in the DAD was ascertained at the time of first hospitalization following catheterization.

Outcomes variables

The outcomes of interest were all cause mortality, as captured by vital statistics, first hospitalization (any cause) and first cardiac procedure (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)) in the first year after the date of coronary catheterization. For those patients with multiple admissions in the following year after coronary catheterization, only the first admission was counted. The outcomes of PCI and CABG were obtained from the APPROACH database, and hospitalizations from the DAD.

Statistical analysis

Descriptive statistics were used to describe study population characteristics. Subjects were considered to be “correctly” coded as obese if they had a diagnosis code of obesity in the administrative database and a BMI ≥ 30 kg/m2 in the measured data contained in APPROACH. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of a diagnosis of obesity as coded in the administrative databases were determined using the physical measurement of obesity as the referent value. Each of these validity indices was calculated over the entire study time period as well as by year (2002 – 2008). The accuracy of coding was then considered across various demographic categories and clinical conditions.

As a second step, we assessed the relative impact of being coded as obese on outcomes, namely hospitalization, PCI or CABG, and mortality. We considered the association between obesity and outcomes in those correctly diagnosed as obese within the administrative data, those diagnosed as obese within APPROACH only, and those diagnosed as obese within APPROACH or the administrative database. The association between outcomes and obesity were evaluated in multivariate logistic regression models. The Odds Ratio (OR) between the outcomes and obesity and their 95% confidential intervals (95%CI) were estimated in logistic regression model while controlling for other factors. Statistical analysis was conducted using SAS Version 9.0.

The study protocol was approved by the ethics review board of the University of Calgary.


A total of 17,380 subjects were included in the initial analysis. Baseline characteristics of these patients are outlined in Table 1. The study population was largely male (56.4%) and 48.6% were aged ≥65 years old. Most subjects underwent coronary catheterization for urgent reasons, including myocardial infarction and unstable angina. In APPROACH, there were 3523 (20.3%) subjects with a BMI ≥ 30 kg/m2 (mean BMI of 32.84 kg/m2). Of these, 83.4% were obesity Class I, 13.5% were obesity Class II, and 3.1% were obesity Class III. In the DAD, 414 patients were coded as being obese.

Table 1. Baseline characteristics of the study population from clinical registry data (APPROACH)

Rates of obesity remained stable year to year (see Table 2). The sensitivity of a diagnosis of obesity in the DAD was low at 7.75%. However, it was highly specific at 99.0%, with Negative Predictive Value (NPV) of 80.8% and a PPV of 65.9% (Table 2). There were minor variations in the sensitivity of an obesity diagnosis, under 10% throughout the study time period. There were no clear trends or improvements in sensitivity over time. Specificity and NPV were excellent throughout the study period, at over 98% and 80% respectively.

Table 2. Obesity prevalence and the validity of hospital discharge abstract (DAD) administrative health database coding of (n = 17380)

Of those 414 subjects coded as obese in the DAD, nearly a third (141) were not actually obese when compared to measured data. These incorrectly coded subjects had a mean BMI of 26.9 kg/m2 (SD 3.6), were older (mean age 63.7 ± 10.8 years vs 62.7 ± 11.0, p-value = 0.3), less likely to be female (33.3% vs 55.3%, p < 0.0001), and more likely to be diabetic (35.5 vs 44.3%, p = 0.0827) than those who were correctly coded as obese in both administrative and clinical data (n = 273).

We further analyzed our data to assess whether or not demographic or clinical factors would influence the PPV of a DAD diagnosis of obesity (Table 2). The prevalence of obesity was higher in female subjects (28.3%) than male (16.6%), and the PPV was commensurately higher. The sensitivity of an administrative database obesity diagnosis was also higher in women. There were no trends across age groups, with the exception of a lower prevalence of obesity and PPV in the elderly (age >75 years) age group. The prevalence of obesity and the PPV was higher amongst those subjects with conditions associated with excess body mass: namely, diabetes and hypertension. This association was strongest for those with diabetes: the prevalence of obesity in patients with diabetes was 29.0%, versus 17.9% in those without; similarly, the PPV of an obesity diagnosis in the administrative database was higher amongst those with diabetes (70.8%) than those without (62.6%). The PPV did not seem to be impacted by a diagnosis of hyperlipidemia, congestive heart failure, or a history of previous myocardial infarction.

We further assessed whether BMI influenced the likelihood that a subject was coded as obese in the administrative database. Of those coded as obese within the administrative database, the large majority (72.9%) were Class I obese; of those not coded as obese, 84.3% were Class I obese, and 2.9% were Class III obese (Table 3). Thus, the higher the BMI by measured data the more likely subjects were to be coded as obesity in the administrative data.

Table 3. Obesity class amongst (1) those coded obese in the DAD administrative health database, and (2) those not coded obese in the DAD administrative health database

As a final step, we wished to determine if obesity as coded in DAD was differentially associated with outcomes in comparison to obesity as determined by physical measurement. Over the course of the study, there were 7547 hospital admissions, 10772 CABG and PCIs, and 703 deaths. In subjects who were obese by DAD, there was no significant association between obesity and re-hospitalization or mortality (Table 4). The same was demonstrated for those “correctly” coded as obese. Considering those subjects who were obese by physical measurement only, obesity was associated with decreased risk of mortality or re-hospitalization, but an increased risk of repeat procedure. The same was seen for subjects who were obese by physical measurement or administrative data.

Table 4. The impact of obesity on one-year outcomes


We have confirmed the findings of previous investigators that administrative data under-coded obesity as a diagnosis. However, once obesity is coded in the data, it is coded relatively accurately, as for other chronic conditions [10]. Administratively captured obesity was more likely in patients with higher classes of obesity or obesity-related complications. Interestingly, despite our suspicion that obesity coding would improve over time with increasing general awareness of the relationship between obesity and disease we found no evidence for this. These finding suggest that administrative databases could not be used for obesity surveillance due to under-reporting but could potentially be used to identify obesity for forming a cohort of obese subjects for follow-up studies.

Despite the general poor capture of obesity in administrative databases, we did find a number of conditions under which obesity is better captured. The PPV of an obesity diagnosis is higher in women than in men, and it is also higher in a number of conditions that are known to be associated with obesity, namely diabetes and hypertension. Additionally, in those cases in which obesity is actually captured, it is captured with great accuracy, as demonstrated by the high PPV seen in this study. However the obese subjects as captured by the administrative database are more likely to be Class III obese than those who are not captured, i.e. there is a bias towards coding those with a higher BMI as obese, missing those who are Class I obese. Thus, the administrative databases are capturing subjects who perhaps already have complications from their obesity, as evidenced by the fact that the PPV of an obesity diagnosis in the administrative database is higher in those with obesity related complications such as diabetes. Cohorts defined using administrative data may therefore show a falsely high correlation between obesity and the development of complications or poor outcomes, as the obese subjects correctly identified in administrative databases are potentially sicker than an average obese subject.

Some work has been done assessing the validity of obesity coding in administrative data in previous studies. In one chart based study by Quan et al, only weight loss, coagulopathy and blood loss anemia were less validly coded than obesity in administrative data. In Switzerland, obesity was under-coded (prevalence 2.2% in 1999, 3.2% in 2001 and 4.1% in 2003) compared with the prevalence in chart ranging 6.6-7.3% but coding improved over years (sensitivity 29.4% in 1999, 39.5% in 2001 and 51.5% in 2003; PPV 92.%, 81.1% and 91.7% in these years, respectively) [13]. Reasons put forth for the poor capture of obesity in administrative data include the fact that obesity is not explicitly mentioned in either physician or nursing notes, and also that coders may intentionally not code diagnoses such as obesity owing to time constraints when doing data abstraction. In the limited time for coding each chart, coders are likely to ignore risk factors, focusing on overt clinical conditions. Coding guidelines pay more attention to conditions contributing to resource use and the use of extra resources by obese subjects is a topic that is only more recently understood [14]. In addition, physicians may not explicitly mention obesity in the chart summary page which coders mainly rely on, as obesity is poorly recognized as a disease. BMI was also not well-documented although height and weight are available on most clinical charts. The diagnosis of obesity is often made based on clinician’s subjective observation, likely capturing higher class obesity. If administrative database data abstractors are coding height and weight in the chart, rates of obesity are likely to be accurate.

Another difficulty in defining obesity is the use of patient self-reported data. On patient admission to hospital, height and weight are frequently determined by patient report, and this information is then recorded in the patient record. It has been shown that patients overestimate their height and underestimate their weight, which leads to underestimates of the prevalence of obesity. This misrepresentation of BMI is more common in the obese [15].

A recent study by Woo et al [16] considered both hospital administrative data and a clinical database that captured height and weight for all children admitted to hospital. The administrative database failed to capture obesity for the majority of obese children who were admitted to hospital. A diagnosis of obesity in the administrative database only had an 8% sensitivity based on their BMI. More importantly, when outcomes were compared between non-obese children and obese children based on (a) obesity as captured in the administrative database versus (b) obesity as captured in the clinical database, the impact of obesity was found to be different. A diagnosis of obesity recorded in the administrative data identified “sporadic, potentially non-representative, hospital discharges with shorter lengths of stay.” However our study demonstrated that the association between obesity and each of the outcomes (hospitalization, PCI/CABG or death) were similar between regardless of how obesity was coded. Differences arose in terms of the significance (for mortality, likely due to the small number of deaths, and for re-hospitalization), and in terms of the magnitude for PCI/CABG.

For missing information on obesity in administrative data, merging with clinical databases such as was done in this study is an important way by which to enhance the quality data found in administrative databases. Additionally, physician claims databases as well as prescription databases are potential sources of obesity information. In a review of available literature, nearly all studies of obesity using larger databases are not based on administrative databases alone. This includes papers from NHANES assessing obesity prevalence [17,18], studies assessing the association between adiposity and cardiovascular outcomes, [19-25] and studies assessing care in obese subjects [26,27]. For instance, in a paper by Chang et al., while Medicare claims and enrollment were used to assess for service utilization, data on BMI were obtained from a merge with the Medicare Current Beneficiary Survey (MCBS). Similar studies done strictly using administrative or claims data without data enrichment to determine BMI would only identify a high risk group of obese subjects [28].


There are a number of limitations in this study that need be noted. Firstly, we have only considered cardiac patients. As cardiovascular disease is a complication related to obesity, rates of obesity coding in administrative data may be higher among this population than in the general inpatient population. However, in a study by Quan et al assessing a random sample of charts, obesity had prevalence 2.7% in ICD-9-CM DAD and 1.9% in ICD-10 DAD [10] similar to the rate seen in this population. We could also only consider the impact of coding on outcomes in cardiac populations; more distinct patient populations need to be assessed.


A call to arms has been put forth by organizations such as the American Heart Association, recognizing that health care providers have not done a good job assessing for obesity and suggesting “the measurement and documentation of BMI in all adults” [29,30]. In this study we have demonstrated that even when obesity is present, care givers and coders do a poor job documenting its presence – though subjects at highest risk of complications are accurately identified. This large study demonstrates three key pieces of information: obesity is underreported in administrative data with low sensitivity, and hence cannot be used for incidence and prevalence surveillance; obesity coding in administrative databases could be used to define a cohort for follow-up or outcomes studies, supported by high PPV and similar outcomes conclusions between two databases; finally, we strongly recommend adding height and weight into routine administrative data coding, as is done age and sex. This would make these data an invaluable resource for studies of obesity and population health.


APPROACH: Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease; BMI: Body mass index; CABG: Coronary artery bypass grafting; CVD: Cerebrovascular disease; DAD: Discharge abstract database; ICD-9-CM: International classification of diseases, ninth revision, clinical modification; MI: Myocardial infarction; NPV: Negative predictive value; PCI: Percutaneous coronary intervention; PPV: Positive predictive value.

Competing interests

The author(s) declare that they have no competing interests.

Authors’ contributions

BJM conceived the project, gathered and concatenated databases, wrote the manuscript. GC conducted data analysis and assisted in manuscript revisions. MG assisted in data interpretation and manuscript revisions. HQ assisted in conceiving the project and edited the manuscript. All authors read and approved the final manuscript.

Authors’ information

BJM is a cardiac surgery resident at the University of Calgary. GC is an associate professor in community health sciences at the University of Calgary. MG is a clinical cardiologist, clinical professor and member of the APPROACH research group at the University of Alberta. HQ Alberta Heritage Foundation for Medical Research Population Health Investigator and an Associate Professor at the Department of Community Health Sciences and the Centre for Health and Policy Study of the University of Calgary.


There are no further contributors to acknowledge.

BJM is supported by a Clinical Fellowship from Alberta Innovates – Health Solutions (AIHS; formerly Alberta Heritage Foundation for Medical Research (AHFMR)). HQ is an AIHS Population Health Investigator.

No specific funding agency or grant supported this project.


  1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM: Prevalence of overweight and obesity in the United States, 1999-2004.

    JAMA 2006, 295(13):1549-1555. PubMed Abstract | Publisher Full Text OpenURL

  2. Stewart ST, Cutler DM, Rosen AB: Forecasting the effects of obesity and smoking on U.S. Life expectancy.

    N Engl J Med 2009, 361(23):2252-2260. PubMed Abstract | Publisher Full Text OpenURL

  3. Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, Hayflick L, Butler RN, Allison DB, Ludwig DS: A potential decline in life expectancy in the United States in the 21st century.

    N Engl J Med 2005, 352(11):1138-1145. PubMed Abstract | Publisher Full Text OpenURL

  4. Wilson PW, D’Agostino RB, Sullivan L, Parise H, Kannel WB: Overweight and obesity as determinants of cardiovascular risk: the Framingham experience.

    Arch Intern Med 2002, 162(16%M doi:10.1001/archinte.162.16.1867):1867-1872. PubMed Abstract | Publisher Full Text OpenURL

  5. Kannel WB, Plehn JF, Cupples LA: Cardiac failure and sudden death in the Framingham Study.

    Am Heart J 1988, 115(4):869-875. PubMed Abstract | Publisher Full Text OpenURL

  6. Kenchaiah S, Evans J, Levy D, Wilson PWF, Benjamin EJ, Larson MG, Kannel WB, Vasan RS: Obesity and the risk of heart failure.

    N Engl J Med 2002, 347:305-313. PubMed Abstract | Publisher Full Text OpenURL

  7. Goodpaster BH, Krishnaswami S, Resnick H, Kelley DE, Haggerty C, Harris TB, Schwartz AV, Kritchevsky S, Newman AB: Association between regional adipose tissue distribution and both type 2 diabetes and impaired glucose tolerance in elderly Men and women.

    Diabetes Care 2003, 26(2):372-379. PubMed Abstract | Publisher Full Text OpenURL

  8. Ross R, Aru J, Freeman J, Hudson R, Janssen I: Abdominal adiposity and insulin resistance in obese men.

    Am J Physiol Endocrinol Metab 2002, 282(3):E657-E663. PubMed Abstract | Publisher Full Text OpenURL

  9. Balkau B, Deanfield JE, Després JP, Bassand JP, Fox KAA, Smith SC Jr, Barter P, Tan CE, Van Gaal L, Wittchen H-U, Massien C, Haffner SM: International Day for the evaluation of abdominal obesity (IDEA): a study of waist circumference, cardiovascular disease, and diabetes mellitus in 168 000 primary care patients in 63 countries.

    Circulation 2007, 116(17):1942-1951. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  10. Quan H, Li B, Saunders D, Parsons GA, Nilsson CI, Alibhai A, Ghali WA: Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database.

    Health Serv Res 2008, 43(4):1424-1441. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  11. Ghali WA, Knudtson ML: Overview of the alberta provincial project for outcome assessment in coronary heart disease. On behalf of the APPROACH investigators.

    Can J Cardiol 2000, 16(10):1225-1230. PubMed Abstract OpenURL

  12. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ: Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.

    N Engl J Med 2003, 348:1625-1638. PubMed Abstract | Publisher Full Text OpenURL

  13. Januel J-M, Luthi J-C, Quan H, Borst F, Taffe P, Ghali W, Burnand B: Improved accuracy of co-morbidity coding over time after the introduction of ICD-10 administrative data.

    BMC Health Serv Res 2011, 11(1):194. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  14. Health Canada: Canadian coding standards for ICD-10-CA and CCI. Published at webcite. 2010. Accessed February 12, 2012.

  15. Gillum RF, Sempos CT: Ethnic variation in validity of classification of overweight and obesity using self-reported weight and height in American women and men: the third national health and nutrition examination survey.

    Nutr J 2005, 4:27. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  16. Woo JG, Zeller MH, Wilson K, Inge T: Obesity identified by discharge ICD-9 codes underestimates the true prevalence of obesity in hospitalized children.

    J Pediatr 2009, 154:327-331. PubMed Abstract | Publisher Full Text OpenURL

  17. Ogden CL, Carroll MD, Kit BK, Flegal KM: Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010.

    JAMA 2012, 307(5):483-490. PubMed Abstract | Publisher Full Text OpenURL

  18. Flegal KM, Carroll MD, Kit BK, Ogden CL: Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010.

    JAMA 2012, 307(5):491-497. PubMed Abstract | Publisher Full Text OpenURL

  19. Benderly M, Boyko V, Goldbourt U: Relation of body mass index to mortality among Men with coronary heart disease.

    Am J Cardiol 2010, 106(3):297-304. PubMed Abstract | Publisher Full Text OpenURL

  20. Lancefield T, Clark DJ, Andrianopoulos N, Brennan AL, Reid CM, Johns J, Freeman M, Charter K, Duffy SJ, Ajani AE, Proietto J, Farouque O: MIG (Melbourne Interventional Group) Registry; Is there an obesity paradox after percutaneous coronary intervention in the contemporary Era?: an analysis from a multicenter australian registry.

    J Am Coll Cardiol Intv 2010, 3(6):660-668. Publisher Full Text OpenURL

  21. King KM, Southern DA, Cornuz J, Maitland A, Knudtson ML, Ghali WA: Elevated body mass index and Use of coronary revascularization after cardiac catheterization.

    Am J Med 2009, 122(3):273-280. PubMed Abstract | Publisher Full Text OpenURL

  22. McTigue K, Larson JC, Valoski A, Burke G, Kotchen J, Lewis CE, Stefanick ML, Van Horn L, Kuller L: Mortality and cardiac and vascular outcomes in extremely obese women.

    JAMA 2006, 296(1):79-86. PubMed Abstract | Publisher Full Text OpenURL

  23. Oreopoulos A, McAlister FA, Kalantar-Zadeh K, Padwal R, Ezekowitz JA, Sharma AM, Kovesdy CP, Fonarow GC, Norris CM: The relationship between body mass index, treatment, and mortality in patients with established coronary artery disease: a report from APPROACH.

    Eur Heart J 2009, 30(21):2584-2592. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  24. Dorn J, Schisterman E, Winkelstein WJ, Trevisan M: Body Mass Index and mortality in a general population sample of men and women.

    Am J Epidemiol 1997, 146:919-931. PubMed Abstract | Publisher Full Text OpenURL

  25. Das SR, Alexander KP, Chen AY, Powell-Wiley TM, Diercks DB, Peterson ED, Roe MT, de Lemos JA: Impact of body weight and extreme obesity on the presentation, treatment, and in-hospital outcomes of 50,149 patients with ST-segment elevation myocardial infarction: results from the NCDR (national cardiovascular data registry).

    J Am Coll Cardiol 2011, 58(25):2642-2650. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  26. Noël P, Copeland L, Pugh M, Kahwati L, Tsevat J, Nelson K, Wang C-P, Bollinger M, Hazuda H: Obesity diagnosis and care practices in the veterans health administration.

    J Gen Intern Med 2010, 25(6):510-516. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  27. Chang VA, Asch DA, Werner RM: Quality of Care Among Obese Patients.

    JAMA 2010, 303(13):1274-1281. PubMed Abstract | Publisher Full Text OpenURL

  28. Chin CT, Chen AY, Wang TY, Alexander KP, Mathews R, Rumsfeld JS, Cannon CP, Fonarow GC, Peterson ED, Roe MT: Risk adjustment for in-hospital mortality of contemporary patients with acute myocardial infarction: The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry®–Get With The Guidelines (GWTG)™ acute myocardial infarction mortality model and risk score.

    Am Heart J 2011, 161(1):113-122.


    PubMed Abstract | Publisher Full Text OpenURL

  29. Cornier MA, Després JP, Davis N, Grossniklaus DA, Klein S, Lamarche B, Lopez-Jimenez F, Rao G, St-Onge MP, Towfighi A, Poirier P: Assessing Adiposity. Circulation. American Heart Association Obesity Committee of the Council on Nutrition; Physical Activity and Metabolism; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing, Council on Epidemiology and Prevention; Council on the Kidney in Cardiovascular Disease, and Stroke Council; 2011.



  30. Health NIo: The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. In Edited by US Department of Health and Human Services PHS, National Institutes of Health, National Heart, Lung, and Blood Institute. Bethesda, MD: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute; 2000. OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here: