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    Question Report - Obesity Q01 - Characterize common indications for bariatric surgery

    Challenger's 'Report Question' button allows people using a course to comment on questions, ask for clarification, or tell us about inaccuracies or issues with a question.  These are sent to an AI model, and to human clinical editors to determine if the question needs to be changed.

    Comments can be as simple as a question being overly complicated for the level of test preparation or CME intended, or point out conflicting guidelines and publications.  We are publishing most of these reports on our blog, to see what other clinicians think.

    Question Obesity Q01 - Characterize common indications for bariatric surgery 
    Path: Family Medicine
    Question Stem A 35-year-old obese man with diabetes, whose blood sugar levels have been averaging 180 to 220 mg/dL, and comorbid osteoarthritis presents to you for a routine follow-up visit. In the last year, 3 diets and 2 exercise programs all resulted in a 5-pound weight loss that the patient quickly regained. He takes metformin, glipizide, and celecoxib. He does not smoke cigarettes, drink alcohol, or use illicit drugs.

    His vital signs are: temperature is 36.8 °C, heart rate 60 beats/minute, blood pressure 115/76 mm Hg, respiratory rate 14 breaths/minute, and oxygen saturation 98% on room air. His height is 1.57 m and he weighs 109 kg. He is alert and in no distress. Apart from obesity, his physical examination is normal.

    What is the next step in the management of his weight?

    Answer 1 Referral to a nutritionist for a low-carbohydrate diet
    Answer 2 Referral to a nutritionist for a low-fat diet
    Answer 3 chest x-ray
    Answer 4 Referral to a bariatric surgeon (correct answer)
    Answer 5

    Referral to a physical therapist

    Educational Objective

    Characterize common indications for bariatric surgery.

    Incorrect Answer Remediation

    Key Point: Bariatric surgery should be considered for patients with a body mass index of > 35 kg/m2 who have failed to lose weight on medical management and have comorbidities related to obesity.

    Explanation: This patient’s body mass index (BMI) is 44 kg/m2. Guidelines recommended considering bariatric surgery for patients with BMIs higher than 35 kg/m2 who have failed to lose weight on medical management and who have comorbidities related to obesity. A meta-analysis concluded that bariatric surgery results in a 20- to 30-kg weight loss, which is maintained for up to 10 years. Randomized studies support the superiority of bariatric surgery over diet and exercise alone in individuals with severe obesity. Subsequent research continues to support this conclusion.

    Although bupropion in combination with naltrexone is approved in the United States for the management of weight loss, bupropion alone is not approved for this use.


    Lim RB. Bariatric operations for management of obesity: indications and preoperative preparation. Updated February 27, 2018. Accessed April 17, 2018.

    Garvey WT, Mechanick JI, Brett EM, et al; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery. Comprehensive Clinical practice guidelines for the medical care of patients with Obesity. AACE Journal, 22; Issue 7, July 2016

    Question has been reported with the following comment:

    The patient is not on all the appropriate medications for his diabetes. Sulfonylureas are known to be weight positive. Changes of his medication to possibly a GLP-1 would be a better first step

    Challenger's AI Responded

    The user's comment indicates a valid point. The patient is currently on a sulfonylurea, glipizide, which can indeed contribute to weight gain and is not the most weight-neutral choice for the treatment of type 2 diabetes. More modern management often involves GLP-1 receptor agonists, which not only help to control blood glucose levels but also can help with weight loss.

    However, the question seems to focus specifically on the management of obesity in the context of BMI, failed attempts at weight loss through diet and exercise, and comorbidities. According to the guidelines mentioned in the explanation, the patient's BMI of 44 kg/m^2 and his failure to lose weight despite multiple attempts could qualify him for consideration of bariatric surgery.

    Still, the user's comment brings an important perspective, emphasizing the need for comprehensive care in managing the patient's diabetes and obesity. Ideally, the question could have been framed to acknowledge the possible modification of the patient's diabetes medications as a part of comprehensive management. This would make the question more complex, however, and may have been beyond the scope intended by the question designer.

    In clinical practice, both strategies—adjusting medications and considering bariatric surgery—may well be a part of this patient's care. The ideal sequence or combination would likely depend on detailed discussions with the patient about his preferences, goals, and overall health context.

    Clinical Editor Response

    The learning objective is "when is referral appropriate", not how to manage diabetes and comorbidities.  Change the stem to say "appropriate medication for his diabetes", or actually change it to appropriate medications for current standard of care, and flag it review as medications change.  Preferably the latter.

    What do you think?