Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 47-year-old man is evaluated during a follow-up examination. He is obese and has hypertension, type 2 diabetes mellitus, and obstructive sleep apnea. He reports that he has always has been overweight, and over the years, his weight has gradually increased to 123 kg (271 lb). During the past 2 years, he has tried several commercial diets; a dietician-monitored, calorie-restricted diet; increased physical activity; orlistat; and a combination of these interventions, all without achieving sustained weight loss. Medical history is also significant for bilateral knee pain and depression. He uses continuous positive airway pressure for his obstructive sleep apnea, and his medications are lisinopril, amlodipine, metformin, paroxetine, and as-needed ibuprofen.

On physical examination, the patient is afebrile, blood pressure is 144/78 mm Hg, pulse rate is 86/min, and respiration rate is 18/min. BMI is 36. Cardiovascular and pulmonary examinations are normal. The abdomen is protuberant without pathologic striae. The knees show bony hypertrophy with crepitus, and there is trace bilateral lower extremity edema.

Laboratory studies are significant for a HbA1c level of 9.1%.

Which of the following is the most appropriate management to help this patient achieve sustained weight loss?

A. Bariatric surgery
B. Hypnosis
C. Lorcaserin
D. Very-low-calorie, physician-monitored diet

MKSAP Answer and Critique

The correct answer is A. Bariatric surgery.

This patient with medically complicated obesity should be referred for bariatric surgery. He has multiple obesity-associated comorbidities including hypertension, inadequately controlled type 2 diabetes mellitus, obstructive sleep apnea, and bilateral knee osteoarthritis. In light of his previously unsuccessful weight loss attempts with diet and pharmacologic agents, he should be referred for bariatric surgery. Referral for bariatric surgery should be considered in all patients with a BMI of 40 or higher and in patients with a BMI of 35 or higher with obesity-related comorbid conditions, such as this patient. The goal of bariatric surgery is weight loss that prevents and treats obesity-associated complications. Candidates should be evaluated by a multidisciplinary team with medical, surgical, nutritional, and psychiatric expertise.

The evidence for the use of hypnosis for weight loss in obese patients is unclear.

Lorcaserin, a brain serotonin 2C receptor agonist, acts as an appetite suppressant. It should be used with caution in patients taking medications that increase serotonin levels, such as paroxetine. Therefore, lorcaserin should be avoided in this patient. Additionally, he has already tried a different pharmacologic agent (orlistat) without sustained weight loss.

Diet for weight loss is one of the key components of obesity treatment. There are many diets available, from high-protein, high-fat diets to very-low-fat diets. They differ in their palatability and ability to suppress appetite in individual patients; however, when effective, these diets achieve the same outcome: calorie deficits that result in weight loss. However, given this patient’s failure to achieve sustained weight loss in the past with multiple dietary interventions, another dieting attempt in this patient will likely be unsuccessful. He should continue dietary, lifestyle (physical activity), and behavioral therapy measures following bariatric surgery.

Key Point

• Referral for bariatric surgery should be considered in all patients with a BMI of 40 or higher and in patients with a BMI of 35 or higher with obesity-related comorbid conditions.

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