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Background: The prevalence of obesity and asthma has increased concurrently over the last decades, suggesting a link between obesity and asthma. However, asthma might not be adequately diagnosed in this population. Aim: To investigate whether not only overdiagnosis but also underdiagnosis of asthma is present in an obese population. Methods: Morbidly obese subjects with or without physician-diagnosed asthma were recruited from a pre-operative screening programme for bariatric surgery, and were characterized using an extensive diagnostic algorithm. Results: 473 subjects were screened; 220 met inclusion criteria, and 86 agreed to participate. Among the 32 participating subjects who had a physician diagnosis of asthma, reversible airway obstruction and/or bronchial hyperresponsiveness could only be detected in 19 patients (59%, 95% CI [0.41-0.76]), whereas in 13 patients (41%, 95% CI [0.24-0.50]) the diagnosis of asthma could not be confirmed (overdiagnosis). In contrast, in the remaining 54 patients, 17 (31%, 95% CI [0.20-0.46]) were newly diagnosed with asthma (underdiagnosis). Conclusion: Besides overdiagnosis, there is also substantial underdiagnosis of asthma in the morbidly obese. Symptoms could be incorrectly ascribed to either obesity or asthma, and therefore also in the morbidly obese the diagnosis of asthma should also be based on pulmonary function testing. [ABSTRACT FROM AUTHOR]