Test Your Knowledge Answer #550

Answer and Critique (Correct Answer = C)

This patient is young, is relatively healthy, and has class 2 obesity (body mass index [BMI] of 35 to 39.9). She has sleep apnea but does not have dyslipidemia, hypertension, or diabetes. Recent guidelines for the pharmacologic and surgical management of obesity include a stepwise approach, starting with intensive lifestyle modification before pharmacotherapy or surgery is considered. Individual goals for weight loss and exercise should be established; patients should have regular follow-up with a dietitian to review these goals.

Key Point

• There is a stepwise approach to the management of obesity that begins with intensive lifestyle modification and may include pharmacotherapy prior to referral for surgery.

An age older than 25 years and the presence of diabetes are not prerequisites for surgical treatment of obesity. Similarly, patients are not required to have tried pharmacotherapy for obesity prior to undergoing surgical treatment. Pharmacotherapy may be considered for patients who have a BMI greater than 30 and no comorbidities and for patients who have a BMI greater than 27 and comorbidities. However, many weight-loss medications have side effects and are contraindicated in pregnancy. In this regard, female patients with diabetes should be counseled to use contraception regularly and would require a pregnancy test before starting pharmacotherapy if needed for obesity. No randomized, controlled trials of surgical versus medical treatment of obesity have been conducted, but observational studies have shown sustained weight loss among patients treated surgically compared with no change in weight among medically treated patients at 10-year follow-up; however, observational studies are subject to selection bias despite efforts to match control patients.

Bibliography

1. Snow V, Barry P, Fitterman N, Qaseem A, Weiss K; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2005;142:525-31. [PMID: 15809464] [PubMed]

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