Question Report - Obesity Q01 - Characterize common indications for bariatric surgery
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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)|
Referral to a physical therapist
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.
Lim RB. Bariatric operations for management of obesity: indications and preoperative preparation. Updated February 27, 2018. Accessed April 17, 2018.
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?