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Most patients with a clinical diagnosis of chronic obstructive pulmonary disease (COPD) have not had spirometry to confirm airflow obstruction (AFO). Overweight and obese patients report more dyspnea than normal weight patients, which may be falsely attributed to AFO. We sought to determine whether overweight/obese patients clinically diagnosed with COPD were more likely to be "misdiagnosed" (lack AFO on spirometry) and subsequently treated with inhaled medications. METHODS: Cohort: U. S. Veterans with a clinical diagnosis of COPD (ICD-9 code and/or inhaled medication use) and spirometry at one of three Pacific Northwest VA Medical Centers. Exposures: overweight and obesity (defined by Body Mass Index (BMI) categories). Outcomes: 1) Airflow obstruction on spirometry. 2) Escalation or de-escalation of inhaled therapies from 3 months before spirometry to 9-12 months after. We used multivariable logistic regression with calculation of adjusted proportions for all analyses. RESULTS: 52% of 5,493 Veterans clinically diagnosed with COPD had AFO. The adjusted proportion of patients with AFO decreased as BMI increased (p-value test of trend <0.01). Among patients without AFO, overweight and obese patients were less likely to remain off medications/have therapy de-escalated (adjusted proportions for normal weight, overweight, obese: 0.69 [95% CI 0.64 - 0.73], 0.62 [95% CI 0.58 - 0.65, p=0.014], 0.60 [95% CI 0.57 - 0.63. p=0.001]). CONCLUSIONS: Overweight and obese patients are more likely "misdiagnosed" with COPD and lack de-escalation of inhaled medications after spirometry demonstrated no AFO. Providers may be missing potential opportunities to recognize and treat other causes of dyspnea in these patients.