CASE STUDY 1

Patient B is a White woman, 52 years of age, with a history of type 2 diabetes mellitus, arthritis, hypertension, and hyperlipidemia who presents for a new patient evaluation. She is 5'2" and weighs 150 lbs. She is currently taking metformin, simvastatin, lisinopril, and celecoxib. On exam, her blood pressure is 150/92 mm Hg; heart rate 84 beats per minute; and respiration 16 breaths per minute. Laboratory analysis demonstrates blood glucose of 140 mg/dL; glycosylated hemoglobin 9.5%; cholesterol 205 mg/dL; low-density lipoprotein (LDL) 115 mg/dL; high-density lipoprotein (HDL) 52 mg/dL; and triglycerides 190 mg/dL. She asks for help in trying to lose weight. She expresses difficulty managing her weight since adolescence and has repeatedly cycled up and down with various fad diets and exercise programs. The patient states that she does not presently exercise because of arthritis in her knees and is confused about what she should or should not be eating. She wants to know if her weight really matters, because she knows plenty of people who are heavier than she and they seem to be fine. If it does matter, she wants to know what she should be doing.

In this example, Patient B's BMI is 27. Her waist circumference is 35.5 inches. Both of these measurements place her at increased risk for morbidity and death. Intervention should be made.

Patient B has several comorbidities, including diabetes, dyslipidemia, hypertension, and osteoarthritis. She is at "very high risk" for premature death. Most of these conditions would improve if her weight were reduced.

Patient B clearly is seeking guidance. She is interested in a treatment plan and illustrates this by seeking additional information despite her failure at past attempts. She must realize that her weight really does matter and indeed is already contributing to her morbidity. Her medical conditions are stable. She is eligible and ready for treatment.

Patient B should be counseled to adopt a diet and exercise regimen. She needs to decrease her calories by 500 calories per day and distribute her calories to 45% to 65% carbohydrates, 25% sugar or less, 20% to 35% fat, and 10% to 35% protein. She should choose an exercise program she enjoys—perhaps swimming, which would not only cause less stress on her joints but may also improve her arthritis. She should start slowly, 10 to 20 minutes several times a week, gradually building up to one hour, five or more times per week.