Monday , November 20 2017

Question 826

Mr. Carlson is a 52-year-old Caucasian grocery store manager you saw last week for a new patient visit. His labs from that visit were significant for elevated random plasma glucose 166 mg/dL, A1C 7.4% and elevated lipids (TG=175 mg/dL, LDL 148 mg/dL, HDL 38 mg/dL, total cholesterol 221 mg/dL). He has returned to your clinic for a follow-up appointment. His physical exam is notable for central abdominal obesity (waist circumference 42”), left eyelid xanthelasma, BP 147/91, HR 72, RR 18, BMI 36 kg/m2, but otherwise normal. A repeat A1C test shows A1C 7.6%. Mr. Carlson smokes between 1 and 1.5 packs of cigarettes daily. After discussing the labs and your findings with Mr. Carlson, you begin collaborating on a management plan. You write prescriptions for metformin, a statin and ACE inhibitor. Mr. Carlson doesn’t think “taking medication will be too tough,” but expresses skepticism about your recommendations for a change in his diet, exercise and smoking programs because he has tried them, without success, in the past. What is considered the starting BMI for consideration of bariatric surgery?

Correct

Answer: C. BMI > 35 kg/m2

Individuals with type 2 diabetes and BMI > 35 kg/m2 may be considered a candidate for bariatric surgery, especially if their diabetes is hard to control with lifestyle modifications and antihyperglycemic medications. The decision to undergo this surgery should not be taken lightly as these patients will need lifelong support and medical management. The pros and cons of the surgery should be discussed with the patient and they should be referred only if they want to pursue it further. Bariatric surgery in individuals with BMIs 30-35 kg/m2 has shown a glycemic benefit, however there is insufficient evidence at this time to routinely recommend it.

Reference(s):

Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.
American Diabetes Association. Standards of medical care in Diabetes – 2013. Diabetes Care. Jan. 2013; 36(Suppl. 1):S11-S66. Available at http://care.diabetesjournals.org/content/36/Supplement_1/S11.full. Accessed Jan. 11, 2013.

Incorrect