A 42-year-old woman comes to the office for a follow-up visit. She has been following a weight-loss program with dietary modification and exercise for the past several months. The patient weighs 110 kg (242 lb) and is 170 cm (5 ft 7 in) tall. BMI is 38 kg/m². In the last 6 months, she has lost 3% of her initial body weight on a balanced, low-calorie (1000 kcal/day) diet. The patient has been strictly adhering to dietary recommendations and exercising "as much as possible" but feels she is not making progress. She also feels hungry all the time. The patient says she is motivated to lose weight but is starting to feel discouraged by her results. Medical history includes hypertension, type 2 diabetes mellitus, and obstructive sleep apnea. Blood pressure is 140/80 mm Hg and pulse is 78/min. Physical examination shows an obese habitus but is otherwise normal. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d864_e2ed_bc81_6f03e5559db0_MD0003_00 This patient has obesity and multiple weight-related comorbidities, including type 2 diabetes mellitus, hypertension, and obstructive sleep apnea. Her weight has failed to improve despite appropriate dietary modifications and exercise. Therefore, medical weight-loss intervention is indicated. Appropriate options include weight-loss medication and referral for bariatric surgery. Weight-loss medication is indicated for patients with a BMI ≥30 kg/m² (obese) and those with a BMI of 25-29.9 kg/m² (overweight) with weight-related complications. Primary first-line options include orlistat and liraglutide; combination drugs, including naltrexone/bupropion and phentermine/topiramate, can also be considered. The choice of drug is individualized based on comorbidities, concurrent medications, and side-effect profile. Weight-loss (bariatric) surgery is indicated for patients with a BMI ≥40 kg/m² and those with a BMI ≥35 kg/m² and additional weight-related comorbidity. Although nonsurgical interventions are often attempted first, medication failure is not required to qualify for weight-loss surgery, and both interventions may be pursued concurrently, with medication initiated while the patient is undergoing preoperative evaluation. (Choice B) Moderate caloric restriction (eg, 1500-2000 kcal/day) is usually adequate for producing weight loss in obese patients. A caloric restriction of 800-1500 kcal/day is generally considered the most aggressive diet that can be sustained. Very-low-calorie diets (<800 kcal/day) have a high failure rate and usually do not yield greater long-term success than conventional diets. (Choice C) Weight-loss diets with various macronutrient contents (eg, low-fat, low-carbohydrate, balanced) have been advocated, but the ideal diet appears to be determined by individual factors and preferences. This patient has already tried a fairly aggressive diet; changing the macronutrient content may make a small difference but is unlikely to provide significant, sustained weight loss. (Choice D) Sympathomimetic weight-loss medications (eg, phentermine monotherapy) are useful for inducing short-term weight loss but are not approved for long-term (≥12 weeks) use and are associated with significant weight regain and minimal long-term benefit. (Choice E) Exercise should be included in any comprehensive program to enhance weight loss, reduce regain, and improve overall well-being. However, exercise alone does not typically lead to significant loss and is unlikely to help this patient achieve her goal. Educational objective: Bariatric surgery is indicated for patients with a BMI ≥40 kg/m² or those with a BMI ≥35 kg/m² and additional weight-related comorbidity. Weight-loss medication is indicated for patients with a BMI ≥30 kg/m² or those with a BMI 25-29.9 kg/m² and weight-related complications. Medication failure is not required for patients to qualify for bariatric surgery; both interventions may be pursued concurrently. References: Bariatric surgery for obesity. (http://www.ncbi.nlm.nih.gov/pubmed/29156184)

A 42-Year-Old Woman Comes to the Office for a Follow-Up