Case Studies

Case Study #1:

Patient with Controlled Hypertension

Patient Information

• 52 year old African American female

• Presented in September 2004 for 1 yr minimum lifestyle change intervention

• Referred by PCP

Patient Information

• Measurements

– Height: 5’ 3”

– Weight: 215 lbs

– Waist Circumference: 41 inches

– BMI: 38.1

Patient Information

• Initial BP: 130/90 mm Hg

• Pulse: 76

• Resting ECG normal

• Laboratory– Glucose 91– TSH: 1.78– LDL-C: 89– HDL-C: 65– TG: 62

Patient Information

• Psychological Screen– Minimal to mild depression

• Binge Eating Disorder Screen– Negative

Patient Information

• Pertinent Past Medical History

– Hypertension x 7 years

– Off treatment for several years

– Recently, PCP started ARB/diuretic combination

– Compliant with medication

– Monitors BP at home frequently

− Generally 130/80

− Systolic occasionally hits 140 “with stress”

Patient Information

• Weight History

– Weighed 150 lbs at age 42 when 18 year old son left for college

– Has gained steadily since that time

– Self-described “emotional eater”

− Between supper and bedtime

Clinical Course

• Entered lifestyle change program September 2004

• Hypocaloric diet– Weight loss of 1 lb per week

• Daily walking program

– Step log with pedometer

– Goal of 7000 – 10,000 steps/day

Clinical Course

• Initial medical evaluation

• Basic nutrition and exercise tips from physician and / or staff

• Follow-up

– Physician visits (minimum once monthly)– Lifestyle change group support classes (if

available)

Monthly BP and Weight LossMonth Weight BP Weight Loss Rx Notes

1 215 138/90 None

2 218 138/90 Sibutramine 10 mg Home BP - 128/80

3 212 130/80 Sibutramine 15 mgMore relaxed; feels better; night eating improved

4 206 130/90 Sibutramine 15 mg

5 203.4 130/88 Sibutramine 15 mgThanksgiving thru Christmas

6 203.8 140/88 Sibutramine 15 mgChristmas thru New Years

7 202 122/80 Sibutramine 15 mg

8 201.2 120/80 Sibutramine 15 mg

9 200.6 122/78 Sibutramine 15 mg 7% body wt lost

Discussion Points

• In this patient with controlled hypertension, no additional difficulty with sibutramine

• Patient has achieved modest but significant weight loss to date, with improvement in blood pressure and emotional eating. Small changes can produce big results!

• Having the patient participate in her own care by recording home blood pressure readings gives the physician an extra measure of safety and involves the patient directly in her own care

Discussion Points

• Patient did not have metabolic syndrome

• Two criteria out of five met; three needed

• Criteria met:

– Waist circumference > 35 in

– Note that any patient with a BMI > 35 does not need a waist circumference measured, as it will be elevated.

– Hypertension

Case Study #2:

Patient Preparing for Weight Loss Surgery

Patient Information

• 20 year old Caucasian female

• Presented in June 2004 for 6 months of lifestyle change preparation prior to open gastric Roux n Y procedure

• Surgeon had initially refused her requests for gastric bypass surgery, but had consented to do the procedure pending proof of her fulfilling her pre-operative lifestyle change commitment

Patient Information

• Measurements

– Height: 5’ 10”

– Weight: 303 lbs

– Waist Circumference: 46.5 inches

– BMI: 43.5

− Accepted criteria for surgery

– BMI 40 without comorbidities

– BMI 35 with comorbidities, in particular type 2 diabetes

Patient Information

• Initial BP: 128/88 mm Hg

• ECG normal

• Initial Lab (fasting)– Glucose: 92

– TSH: 2.912

– Total Cholesterol: 155

– LDL: 91

– HDL: 41

– TG: 115

Patient Information

• Psychological Screen

– Minimal to mild depression

• Initial diagnoses of:

– Morbid obesity

– Mild depression

– Metabolic syndrome (elevated waist circumference, low HDL, elevated diastolic BP)

Clinical Course

• Hypocaloric meal plan– Minimum of 1 lb per week

• Physical activity– Pedometer – avg 6,000 steps daily

– Swimming or walking – 30-45 minutes, 3-4 times per week

– Resistance bands or dumbbell work– 2-3 sessions per week

• Sibutramine – 10 mg daily

Clinical Course

• Follow-up– Monthly physician visit

– Lifestyle change group support classes

Outcomes

• Month 2

– Sibutramine increased to 15 mg

– BP = 120/84

– Weight loss at least 1 lb per week

– Patient felt medication was helping, and was willing to increase the dose to optimize intended effects. No adverse effects noted at 10 mg.

Outcomes

• Month 5

– Weight loss = 32 lbs

– Surgeon agreed to proceed with surgery at BMI 39.0

– Underwent surgery in December 2004

− Sibutramine discontinued immediately pre-operatively

Outcomes

• Post-op– Weight loss = 53 lbs in first five months

– Exercises frequently

– Continues in lifestyle change program− Monthly physician visits

− Group support classes

• March 2005– Weight: 218.5 lbs

– Blood pressure: 120/74

Discussion Points

• Bona fide lifestyle change programs will become mandatory for pre-certification of obesity surgery

• Pre-operative sibutramine during initial lifestyle change supported this highly motivated patient

Case Study #3:

Obese Patient Participating in INTENSIVE Lifestyle Modification Program

Intensive Lifestyle Change Program

• This case illustrates one type of comprehensive multi-disciplinary approach

• The purpose is not to discourage PCPs, but rather to stimulate the practitioner to consider create their own system, within “what works” in their own practice

Patient Information

• 53 year old Caucasian female

• Presented in February 2004

• Heard about program through a hospital -sponsored event, featuring a bariatric surgeon and the director of the medical weight loss and lifestyle change program

Patient Information

• Married, with two grown children

• Family relationships are stable– Husband is supportive of participation in the program

• IT professional in a high stress office management position

Patient Information

• Measurements

– Height: 5’ 7”

– Weight: 260 lbs− Desired goal weight: 140 lbs

– Waist Circumference: 47 inches

– BMI: 41

Patient Information

• Weight History

– Age 25: 125-130 lbs− Pregnancies resulted in large weight gains

– Two previous attempts at significant weight loss− 1989: Lost 30 lbs (Weight Watchers); regained in 1 year

− 1998: Lost 70 lbs (dietitian coach); regained in 2 years

– Both parents are obese

– Husband is 50 lbs overweight

– One child is overweight

• No current physical activity

Patient Information

• Medical History– Hypercholesterolemia

– Menopause

• Medications– Simvastatin

– HRT

– Calcium-D

• Psychological– Screening evaluation normal

– Binge Eating Disorder not present

Clinical Course

• One-year, multidisciplinary lifestyle change, weight loss, and weight loss maintenance program for high body mass index adults

• After one year, she will have the option to continue for additional six-month or one-year increments

Clinical Course

• Initial office evaluation– Medical and nutrition history

– Cardiovascular risk factor/obesity focused physical examination

– Laboratory and EKG

– Body composition by impedance technique (repeated every three months)

– Depression and binge eating disorder screening

– Prescription medication option discussed, if appropriate− Patient chose no meds

Clinical Course

• Saturday workshop (group class)– 6 hour all-day session

− Entry point into system for all new patients

– 120 page workbook on nutrition, exercise, mind-body connections

– Personal plan for 1 lb per week weight loss− Balanced ADA-AHA type approach

– Hands-on label reading, healthy recipe substitutions, supermarket product demonstration, pulse taking, target heart rate, weight training, and walking session

Clinical Course

• Follow-up monthly doctor visit– Weight and vital signs check

– Support group attendance reviewed

– One-on-one personal coaching

– Workshop “promises” continually reviewed and updated

– Weight loss medication refilled− If support group attendance requirements met

Clinical Course

• Follow-up one hour support group classes– Six one-hour classes available monthly

– Two classes monthly required for medication refill

– Rotating topics (nutrition, exercise, behavior change, medical)

– Morning and evening classes available

ResultsMonths 1-5

Month Weight# Support Classes Exercise Comments

Start 262 Initial wkshp No weight loss rx

1244

(- 18)5

Pedometer at

6000 steps/day

Keep food logs; Not eating enough

2237.4

(- 6.6)4

Same, plus resistance bands

Calories at 1500; Food log 2 d/wk

3226.5

(- 10.9)4

Pedometer at 8K, plus bands

10% weight loss; continue to journal

4220.6

(- 5.9)4

Adding weight training

Husband has lost 10 lbs

5216

(-4.6)2

6K pedometer daily, weights at

night 3-4x/wk

Excited about getting under 200 lbs

Month Weight# Support Classes Exercise Comments

6207.5

(- 8.5)2

Weights and cardio 5x/wk

Rotate upper/lower body weight work

7205.2

(- 2.3)2 Same

PCP to stop simvastatin soon

8201.0

(-4.2)2 Same “This is my plan!”

9197.5

(-3.5)2 Same

Under 200 lbs. Thanksgiving is next week

10200.8

(+ 3.3)1 Down to 3x/wk

First month at < 2 classes. Not quite back on track. Back to basics

ResultsMonths 6-10

Month Weight# Support Classes Exercise Comments

11 200.8 145 min, 5 days/wk

Feeling better with ↑ exercise. Good Xmas and New Year. Goal was to not gain and restart exercise

12197.5

(- 3.3)2 9000 steps daily

Feels back on track

13194.6

(-2.9)3 Starting pilates

LDL normal; off simvastatin for 3 months

ResultsMonths 11-13

Total Loss = 67.4 lbsBMI = 30.4

Discussion Points

• What qualifies as a bona fide lifestyle change program?

• What coaching/expectations are reasonable between Thanksgiving and New Years?

Case Study #4:

Patient with Obesity, Hypertension and

Type 2 Diabetes

Patient Information

• 32 year old African American female

• Divorced with 2 children

• Works as a legal secretary in a high pressure law firm

• Presents to new PCP after being “burnt out” by her last two physicians

Patient Information

• Measurements

– Height: 5’ 3”

– Weight: 246 lbs

– BMI: 39

Patient Information

• Initial BP: 146/94 mm Hg

• Laboratory– Glucose 136 (fasting)– LDL-C: 130– HDL-C: 36– TG: 198– Total cholesterol: 149– SGOT: 19– SGPT: 14– Alk Phos: 86

• Cardiac Risk Ratio: 4.1

Patient Information

• Pertinent Past Medical History

– 2 normal pregnancies/deliveries

– No current medications

– Describes herself as “tense, anxious, sleep deprived and fat”

Clinical Course

• Initial medical evaluation

• Opportunity for patient to vent frustrations. With listening, the physician built the patients trust and inspired hope

• Physician-patient discussion re: hypertension, type 2 diabetes and the relationship of both to her weight. The metabolic syndrome and its relationship to CHD and sudden cardiac death was also discussed

• Follow-up

– Physician visits (minimum once monthly)

Clinical Course

• Medication prescribed:

– Enalapril 2.5mg daily

– Metformin 500mg BID, with meals

• Basic nutrition, exercise tips and diabetes education from physician and / or staff

• Patient motivated to decrease weight when she understood that all of her medical problems could possible be resolved by weight loss

Monthly Summary/Progress

Month Weight BP Rx Notes

1 246 146/94 Enalapril, Metformin

2 238 138/90 Enalapril, Metformin

Still feeling motivated, taking stairs at work. Feels “healthier”, reports having more energy

3 231 125/80 MetforminD/C enalapril, pt continues to be motivated, do well

4 224 129/80 Metformin

Pts blood sugar improving, will D/C metformin next month if continuing to do well

Case Study #5:

Patient with Obesity and

Hypercholesterolemia

Patient Information

• 54 year old white male

• Married with 1 grown son

• Works at a high stress/high pressure advertising agency. Must socialize with clients over meals frequently.

• Is motivated to lose weight, but does not want to use an “appetite suppressant” or any drug which might affect his mind or personality

Patient Information

• Measurements– Weight: 252 lbs– BMI: 35

• Laboratory– Glucose 98– Cholesterol (total) 310– Triglycerides 264– LDL 146– HDL 35– Cardiac Risk Ration 6.0– SGOT 31– SGPT 34– Alk Phos 48

Patient Information

• Pertinent Past Medical History

– Mild osteoarthritis in both knees

– Seasonal allergies

– No current medications

– Feels he eats out of “obligation and duty” and that hunger is not his problem, but the presence of too much high fat food in a business/social environment

Clinical Course

• Initial medical evaluation

• Started on low calorie, reduced fat and carbohydrate diet amounting to 1800-2000 calories/day in a structured eating pattern. Allows for no snacks or alcohol.

• Physician-patient discussion re: orlistat, its benefits and side effects.

• Follow-up

– Physician visits (minimum once monthly)

Clinical Course• Medication prescribed:

– Orlistat 120 mg daily with his biggest meal

• Basic nutrition and diet instruction

• Patient started medication on a Friday and reported that on Saturday after a low fat meal he went to the movies and “forgot” not to eat buttered popcorn. He experienced an episode of lower abdominal cramps and rectal urgency with increased flatus and a large amount of oily stool. He was unable to get to the bathroom to avoid soiling his pants. The patient was initially angry and frustrated. He called the office on Monday, and realized he had learned about orlistat the hard way. However, he felt motivated because he could see the drug working

• After 3 months, the patient is doing well and has lost 18 pounds (7% of total body weight). He is aware of the drug side effects and wishes to continue with the program.