A 43-year-old woman is evaluated during a follow-up appointment for obesity. She has been following a reduced-calorie, low-fat diet and participating in a 45-minute aerobic exercise class three times weekly for the past 6 months. After her last follow-up appointment 1 month ago, she added 30 minutes of brisk walking on the weekend to her exercise regimen. She brings a food diary and weekly weight records to her appointment. She lost an average of 0.2 kg (0.5 lb) per week over the first 3 to 4 weeks, but her weight loss tapered thereafter and her weight has increased by 0.5 kg (1 lb) since her last visit. The total amount of weight lost over the past 8 months is 2.7 kg (6 lb), or 3% of her original weight. The patient reports that she is unable to achieve the calorie reduction recommended, stating that she is “hungry all the time.” Medical history is also significant for type 2 diabetes mellitus and hypertension. Medications are amlodipine, lisinopril, and metformin.
On physical examination, blood pressure is 141/92 mm Hg, and other vital signs are normal. BMI is 31. The remainder of the examination is unremarkable.
Which of the following is the most appropriate next step in treatment?
A. Bariatric surgery
C. Switch to a low-carbohydrate diet
D. Switch to a very-low-calorie diet
MKSAP Answer and Critique
The correct answer is B. Liraglutide. This item is available to MKSAP 18 subscribers as item 38 in the General Internal Medicine section. More information about MKSAP 18 is available online.
Liraglutide is the most appropriate next step in treatment. Weight-loss medications are recommended when a trial of comprehensive lifestyle modification, including reduced dietary intake, exercise, and behavioral therapy, fails to achieve a 5% to 10% reduction in weight at 3 to 6 months. This patient has appropriately adhered to dietary caloric restriction, with regular self-monitoring of calorie intake and weight, and is now exercising for more than 150 minutes per week. Her BMI is greater than 27, and she has obesity-related comorbid conditions (type 2 diabetes mellitus and uncontrolled hypertension). Liraglutide has been shown to increase satiety and aid in achieving more than 5% weight loss after 52 weeks of therapy, and it may help the patient feel less hungry.
Bariatric surgery is recommended for patients with BMI of 40 or greater, and for patients with BMI of 35 or greater who have obesity-related comorbidities and who have tried all other weight loss therapies without achieving significant weight loss or improvements in comorbid conditions.
There is no evidence that low-carbohydrate diets are more effective for reducing weight than low-fat diets. This patient is adherent to her chosen diet but has difficulty reducing her caloric intake to achieve continued weight loss. Clinicians should prescribe a diet with which the patient will adhere (that is, a diet that is palatable and affordable) and that maintains negative energy balance in order to achieve weight loss.
Very-low-calorie diets are recommended when rapid weight loss is medically indicated. This patient does not require rapid weight loss, and neither the risk nor the expense of frequent visits and laboratory monitoring are justified in this case.
- Weight-loss medications are recommended when a trial of comprehensive lifestyle modification, including reduced dietary intake, exercise, and behavioral therapy, fails to achieve a 5% to 10% reduction in weight after 3 to 6 months.