Lifestyle and Behavior
Case Study: A Patient With Diabetes and
Weight-Loss Surgery
Sue Cummings, MS, RD, LDN
Case Presentation
A.W. is a 65-year-old man with
type 2 diabetes who was referred
by his primary care physician to the
weight center for an evaluation of
his obesity and recommendations for
treatment options, including weight-
loss surgery. The weight center has a
team of obesity specialists, including
an internist, a registered dietitian
(RD), and a psychologist, who per-
form a comprehensive initial evalua-
tion and make recommendations for
obesity treatment. A.W. presented
to the weight center team reluctant
to consider weight-loss surgery; he
is a radiologist and has seen patients
who have had complications from
bariatric surgery.
Pertinent medical history. A.W.'s
current medications include 30 and 70
units of NPH insulin before breakfast
and before or after dinner, respectively,
850 mg of metformin twice daily,
atorvastatin, lisinopril, nifedipine,
allopurinol, aspirin, and an over-the-
counter vitamin B
12
supplement. He
has sleep apnea but is not using his
continuous positive airway pressure
machine. He reports that his morning
blood glucose levels are 100130
mg/dl, his hemoglobin A
1c
(A1C) level
is 6.1%, which is within normal limits,
his triglyceride level is 201 mg/dl, and
serum insulin is 19 ulU/ml. He weighs
343 lb and is 72 inches tall, giving him
a BMI of 46.6 kg/m
2
.
Weight history. A.W. developed
obesity as a child and reports having
gained weight every decade. He is
at his highest adult weight with no
indication that medications or medi-
cal complications contributed to his
obesity. His family history is positive
for obesity; his father and one sister
are also obese.
Dieting history. A.W. has
participated in both commercial
and medical weight-loss programs
but has regained any weight lost
within months of discontinuing the
programs. He has seen an RD for
weight loss in the past and has also
participated in a hospital-based,
dietitian-led, group weight-loss pro-
gram in which he lost some weight
but regained it all. He has tried many
self-directed diets, but has had no
significant weight losses with these.
Food intake. A.W. eats three
meals a day. Dinner, his largest meal
of the day, is at 7:30
p
.
m
. He usually
does not plan a mid-afternoon snack
but will eat food if it is left over from
work meetings. He also eats an eve-
ning snack to avoid hypoglycemia.
He reports eating in restaurants two
or three times a week but says his
fast-food consumption is limited to
an occasional breakfast sandwich
from Dunkin' Donuts. His alcohol
intake consists of only an occasional
glass of wine. He reports binge eating
(described as eating an entire large
package of cookies or a large amount
of food at work lunches even if he is
not hungry) about once a month, and
says it is triggered by stress.
Social history. Recently divorced,
A.W. is feeling depressed about his
life situation and has financial prob-
lems and stressful changes occurring
at work. He recently started living
with his girlfriend, who does all of
the cooking and grocery shopping
for their household.
Motivation for weight loss.
A.W. says he is concerned about his
health and wants to get his life back
under control. His girlfriend, who
is thin and a healthy eater, has also
been concerned about his weight.
His primary care physician has been
encouraging him to explore weight-
loss surgery; he is now willing to
learn more about surgical options.
He says that if the weight center
team's primary recommendation
is for weight-loss surgery, he will
consider it.
Questions
1. Does A.W. have contraindica-
tions to weight-loss surgery, and,
if not, does he meet the criteria
for weight-loss surgery?
2. What type of weight-loss surgery
would be best for A.W.?
Discussion
Roles of the obesity specialist team
members
The role of the physician as an
obesity specialist is to identify and
evaluate obesity-related comorbidi-
ties and to exclude medically treat-
able causes of obesity. The physician
assesses any need to adjust medica-
tions and, if possible, determines if
the patient is on a weight-promoting
medication that may be switched to
a less weight-promoting medication.
The psychologist evaluates
weight-loss surgery candidates for a
multitude of factors, including the
impact of weight on functioning,
current psychological symptoms
and stressors, psychosocial history,
eating disorders, patients' treatment
preferences and expectations, moti-
vation, interpersonal consequences
of weight loss, and issues of adher-
ence to medical therapies.
The RD conducts a nutritional
evaluation, which incorporates
anthropometric measurements
including height (every 5 years),
Clinical Decision Making
Diabetes Spectrum Volume 20, Number 3, 2007
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