MKSAP quiz: Obese patient with elevated fasting glucose

This month's quiz asks readers to evaluate a 48-year-old woman who is concerned about her gradual weight gain over the years and requests counseling on how she can most effectively lose weight.


A 48-year-old woman is evaluated during a routine examination. She is concerned about her gradual weight gain over the years and requests counseling on how she can most effectively lose weight.

Over 8 years, she has gained approximately 18 kg (40 lb). With several commercial diets, she has lost weight but always gains it back. She has a sedentary job, and often skips breakfast or eats dinner on the run. She states she cannot fit exercise into her busy day. She takes no medications and has no allergies.

On physical examination, temperature is normal, blood pressure is 132/70 mm Hg, pulse rate is 80/min, and respiration rate is 12/min. BMI is 32. There is no thyromegaly. The abdomen is obese, soft, nontender, and without striae. Fasting plasma glucose level is 106 mg/dL (5.9 mmol/L) and thyroid function test results are normal.

Which of the following is the most appropriate next step to help this patient achieve long-term weight reduction?

A. Exercise 15-30 minutes 5 days/week
B. Laparoscopic adjustable band surgery
C. Orlistat
D. Reduce current caloric intake by 500-1000 kcal/d


MKSAP Answer and Critique

The correct answer is D. Reduce current caloric intake by 500-1000 kcal/d. This item is available to MKSAP 16 subscribers as item 51 in the General Internal Medicine section. Information about MKSAP 16 is available online.

This patient should reduce her current caloric intake by 500 to 1000 kcal/d. Consistent reduction in daily dietary caloric intake is the most successful long-term and safest weight loss strategy in obese and overweight patients. Patients who follow a diet that reduces their caloric intake by 500 to 1000 kcal/d as compared with their intake that is currently maintaining weight will lose an average of 0.45 to 0.91 kg (1-2 lb) per week. The initial goal should be a loss of 10% of total body weight. If this patient adheres to this recommendation, she should lose 9.1 kg (20 lb) in 4 to 5 months. This degree of weight loss has been shown to decrease the health-related consequences of obesity, including diabetes mellitus. Because she already has prediabetes, weight loss is important to her long-term health.

Exercise is an important part of a comprehensive weight loss program that focuses on lifestyle modification. However, without attention to eating habits and caloric restriction, exercise alone is not adequate for weight loss.

Current National Institutes of Health and Veterans Affairs guidelines recommend consideration of bariatric interventions, such as laparoscopic band surgery, in patients with a BMI greater than 40 or patients with a BMI of 35 to 40 with obesity-related comorbidities, such as diabetes mellitus, obstructive sleep apnea, or severe joint disease. This patient does not meet these recommendations.

Orlistat is a lipase inhibitor that leads to fat malabsorption. It is FDA approved when used in conjunction with a reduced calorie diet. It is moderately effective in weight loss (2.9 kg [6.4 lb] at 12 months) but gastrointestinal side effects are common. More serious adverse effects, such as severe liver injury and malabsorption of fat-soluble vitamins, have been reported. Lifestyle management with diet and exercise should be the first step in any weight loss program. Medications can be used in conjunction with, but not as a substitute for, diet and exercise.

Key Point

  • Consistent reduction in daily dietary caloric intake is the most successful long-term and safest weight loss strategy in obese and overweight patients.