27 Obesity and anti-obesity medical and surgical management
Case, Part 1
SB is a 48-year-old woman with type 2 diabetes mellitus, hypertension and hyperlipidemia who presents for weight loss. She reports struggling with weight since childhood but started gaining most significantly after her pregnancies, the last of which was at 28 years of age. She has tried several popular diets, including diet books and diet centres. She has also tried pills for weight loss, both ‘over the counter’ and ordered from television without success. Her current diet consists of a fast food sandwich and large diet soda in the mid-morning ‘on the run’, a piece of fruit with cheese and crackers at home in the mid-afternoon, and large meal with a meat, starch and vegetable for dinner with her family at home four nights a week and eating out the other three. In the evening, she snacks on a piece of cake, ice-cream or popcorn. She craves sweets, especially when stressed, and struggles with large portion sizes. She wants to avoid surgery if possible, but is open to hearing more about it. Her family history is significant for obesity in her mother and two of her three siblings, and hyperlipidaemia in her father and mother. She takes rosiglitazone 2 mg-metformin 1000 mg twice daily, insulin aspart 20 units with each meal, insulin glargine 45 units at bedtime, simvastatin 40 mg daily and lisinopril 20 mg twice daily. Pertinent physical exam findings include a weight of 126 kg, height of 162 cm, and body mass index (BMI) of 48.0 kg/m2. She has a waist of 42 inches. Her labs are unremarkable.
Medical Management
Pharmacotherapy and behaviour modification are the mainstays of non-surgical treatment of obesity, with behaviour modification being the oldest approach to weight loss. Most commonly applied as a program of decreased caloric intake coupled with increased physical activity, behavioural programs have been effective in curtailing weight gain and improving overweight and moderate obesity; however, these behaviour changes and resultant weight loss are difficult for patients to sustain. Additionally, the magnitude of weight loss only modestly improves the health of patients with morbid obesity, those in the greatest need for weight management. Behaviour modification programs usually result in loss of 5–10% of body weight over a 6-month period, but this loss is rarely maintained beyond 6–12 months. High protein, low-carbohydrate diets have had some recent popularity, but a study has shown that at 1 year there was little difference in outcome when such a diet was compared with a conventional diet. Very-low-calorie diets result in more rapid weight loss, but are not a long-term solution without significant, sustained behaviour modification. The risk of malnutrition and need for frequent changes to medication make medical supervision imperative, increasing the cost and decreasing the ease of access to this type of program.
