A 47-year-old woman with primary hypothyroidism and osteoarthritis of the right knee presented to the clinic for follow-up. She is trying to lose weight in preparation for right knee surgery. The weight loss has plateaued on a low-calorie meal plan. Her exercise is limited by chronic knee pain. She tracks her calories and daily steps. After the discussion about the risks and benefits of weight loss medications, she was started on phentermine/topiramate extended-release daily. She returns three months later and has lost 3% of her body weight since the last visit. On physical examination, her BMI is 34 kg/m². She has decreased range of motion of right knee. Otherwise, the physical examination is unremarkable.
A 63-year-old African American male with a history of obesity, T2DM, CKD3b and recent NSTEMI was referred for cardiometabolic risk optimization.
- Heavy in starchy and refined carbohydrates, “meat & potatoes,” and casseroles
- Doesn’t snack much and avoids sweets or baked goods during the day and evening but eats fruit for dessert
- No sugar-sweetened beverages and rare alcohol
Exercise: states he has always been physically active with his work but has been in cardiac rehab three times weekly for the past 6 weeks
Sleep: has OSA treated with cpap
Exam: BMI 37 and waist circumference 111cm; BP 140/90; pulse 66
Labs: HbA1c 7.6%, eGFR 44, total cholesterol 145, HDLc 45 mg/dL, trig 160 mg/dL, LDLc 68 mg/dL, albumin 4, ALT 35, platelets 300,000, urine albumin:creatinine 320
A 27 year-old woman with a history of obesity, polycystic ovary syndrome (PCOS) and primary hypothyroidism is referred to you for recent weight gain. She also has a history of recurrent kidney stones. Despite her best efforts to follow a meal plan as prescribed by a registered dietitian and increasing her physical activity by hiring a personal trainer, she has gained 20 pounds in the 6 months prior to her visit with you. She reports recent trouble with portion control. She generally eats three large meals per day and craves salty snacks like potato chips and tortilla chips in the evening while watching TV.
She was evaluated by another endocrinologist who documented a normal 11 pm salivary cortisol, fasting glucose, glycated hemoglobin A1c (HbA1c), and thyroid-stimulating hormone (TSH) level. Her past medical history is unremarkable. Her only medication is levothyroxine 100 mg daily. Her family history is notable for obesity and type 2 diabetes mellitus (T2DM) in her father. Her mother had medullary thyroid cancer but is currently free of disease. She is married, but does not desire to start a family yet, wishing to focus on her personal health first.
On review of systems, she has generalized anxiety and trouble sleeping. Menses are irregular. On physical examination, her heart rate is 88 beats/minute, and her blood pressure is 125/80 mm Hg. Her body mass index (BMI) is 36 kg/m2 (normal, 18.5 to 24.9 kg/m2), and her waist circumference is 96.5 cm. She has mild facial hirsutism on the chin and upper lip. The thyroid gland is minimally enlarged, but there are no palpable nodules. An ultrasound performed 6 months ago also did not show any nodules.
A 58 year-old man is referred to see you for a fasting glucose of 108 mg/dL (normal, 70-100 mg/dL). He has a past medical history of hypertension treated with atenolol 25 mg daily and hypercholesterolemia treated with atorvastatin 20 mg daily. His only regular physical activity is walking four blocks to and from a diner each day at lunchtime. His father was a heavy smoker and had a myocardial infarction (MI) at age 43 years. On review of systems, he complains of fatigue, dyspnea on exertion, gastroesophageal reflux, lower extremity edema, snoring, sleep disturbance, loss of libido, erectile dysfunction, and a depressed mood without suicidal thoughts or ideation.
On physical examination he has a body mass index (BMI) of 38 kg/m2 (normal, 18.5 to 34.9 kg/m2), blood pressure of 150/94 mm Hg, resting heart rate of 84 beats/minute, a neck circumference of 42 cm, a waist circumference of 109 cm, a crowded oropharynx, and 2+ pitting edema of the pretibial surfaces. Thyroid, lung, cardiac, abdominal, genital, and peripheral arterial exams are normal.
Review of outside labs also includes a total cholesterol of 250 mg/dL (desirable, <200 mg/dL), triglycerides of 500 mg/dL (desirable, <150 mg/dL), and high density lipoprotein cholesterol (HDL-C) of 27 mg/dL (desirable, = 60 mg/dL). The patient's calculated LDL cholesterol (LDL-C) could not be determined due to the high triglycerides.
An older man with obesity and type 2 diabetes, without hypertension, comes for a second opinion about dietary management. His primary care physician recommends that he switch to a Mediterranean diet supplemented with mixed nuts, without worrying about energy restriction. The patient is concerned that such an approach will worsen his cardiovascular risk.
A 55 year-old woman with a strong family history of both coronary artery disease and type 2 diabetes mellitus (T2DM) comes for evaluation. She has a 6-year history of hypertension, a long-standing problem with obesity, and pre-diabetes revealed by recent laboratory testing. She questions whether a low fat or low carbohydrate diet would be helpful in reducing her risk of coronary artery disease.
A 28 year-old woman seeks advice about prevention of gestational diabetes mellitus. Three of her sisters have had pregnancies complicated by gestational diabetes mellitus (GDM). Although good randomized trial data evaluating whether specific diets can prevent gestational diabetes are lacking, she was advised to lose weight. Eighteen months later, the patient has not succeeded in losing any weight, but has become pregnant. She continues to follow a typical Western diet with an abundance of processed food. She walks for 20 minutes five days per week. She comes to your office at 26 weeks of gestation because her glucose tolerance test showed gestational diabetes.
A 54 year-old woman is scheduled for surgical neck exploration and laryngectomy for the recurrence of a laryngeal squamous cell carcinoma. She was initially treated with external beam radiation to the neck 3 years prior when she was first diagnosed. Over the past 6 months, she has lost 35 lbs, which was attributed to increased dysphagia and reduced appetite during this time. Despite strong support of family members and friends and a large supply of oral nutritional supplements at home, the patient is unable to meet her nutritional needs with oral intake. Her current weight is 93 lbs (42 kg), and her height is 65 inches (165 cm), giving her a body mass index (BMI) of 15 kg/m2 (normal, 18.5 to 24.9 kg/m2).
Her other medical history includes hypothyroidism that developed 6 months after radiation therapy and hypertension. She previously smoked one pack of cigarettes daily for 25 years, but quit 10 years prior. She has mild emphysema and only rarely requires rescue inhalers for symptoms of wheezing.
Her oral medications include levothyroxine, amlodipine, as well as opiate medications for pain. Two weeks prior to her scheduled surgery, the patient is admitted for nutritional optimization and a gastric feeding tube is placed.
- A 42 year-old woman who presently weighs 215 lbs (99 kg) and has undergone Roux-en-Y gastric bypass surgery two years prior. Postoperatively, she sustained a weight loss of 110 lb (50 kg) over 20 months, though she has gained 2.5 lbs (1 kg) in the past month. She continues to experience intermittent loose bowel movements and hair loss.
- A 56 year-old otherwise healthy man presents to the emergency department with two days of fevers, severe abdominal pain, nausea, and an inability to tolerate food by mouth. Diverticulitis is confirmed on computerized tomography (CT) scan. Serum pre-albumin is measured to be 16 mg/dL (normal, 20-40 mg/dL)
- A 37 year-old male with history of Crohn’s disease has sustained four exacerbations in the past year, requiring bowel rest and corticosteroids. He continues to have 5-10 bowel movements daily and has lost 15 lbs (7 kg) over the past 3 months. His current weight is 132 lbs (60 kg), with a body mass index of 20 kg/m2 (normal, 18.5 to 24.9 kg/m2).
- A 72 year-old female with a history of chronic obstructive pulmonary disease (COPD) and hypertension is transferred to the intensive care unit (ICU) for sepsis and respiratory failure two days after she was admitted to the hospital for a COPD exacerbation. She requires mechanical ventilation through an endotracheal tube. Due to hypotension, she requires continuous infusion of adrenergic agonists (pressors) and her glomerular filtration rate has declined by 30% since admission. Her weight is 165 lbs (75 kg), and her body mass index is 26 kg/m2 (normal, 18.5 to 24.9 kg/m2).
A 47 year-old white man of Italian descent with a strong family history of type 2 diabetes and cardiovascular disease was recently diagnosed with prediabetes. He has always been proud that he does not have any chronic disease and has never needed to take any medications, despite having a weight problem. He does not follow any specific diet plan, but is very active. He is currently doing 150 minutes of moderate intensity physical activity every week. He cooks most of his meals and rarely dines out. His meals, in general, are high in carbohydrates as he loves pasta, pizza, and bread. He also adds olive oil to most of his meals and eats fatty fish two times per week. He does not eat much red meat, but eats a lot of processed meat and cheese. During his last visit to his primary care physician, his fasting plasma glucose was 110 mg/dL (normal, 70-100 mg/dL), and his glycated hemoglobin (HbA1c) was 6.1% (normal, <5.7%). He was shocked by the results. Except for obesity, he does not have any other health problems. When your dietitian reviewed his 3-day food log, she found that he consumes approximately 2800 calories per day with total carbohydrates comprising 60% of his diet.
- Weight: 206 lbs (93.6 kg)
- Height: 67 inches (170 cm)
- Body mass index (BMI): 32 kg/m2 (normal, 18.5 to 24.9 kg/m2)
- Waist circumference: 40 inches
- Blood pressure: 130/80 mm Hg
- Low density lipoprotein cholesterol (LDL-C): 98 mg/dL (desirable, <100 mg/dL)
- High density lipoprotein cholesterol (HDL-C): 42 mg/dL (desirable, ≥60 mg/dL)
- Triglycerides (TG): 186 mg/dL (desirable, <150 mg/dL)
His internet search led him to read the results of the diabetes prevention program, which showed that weight loss reduces type 2 diabetes risk by 58%. He stated that he was in the best shape, and he would like to reach that goal over the next 8 weeks by reducing total caloric intake to 1000-1200 calories/day and increasing his activity to 50 minutes on 5 days of the week to a total of 250 minutes/week. He came to you for advice regarding healthy eating patterns and physical activity that will help him to prevent type 2 diabetes.
A 45 year-old female who is “health conscious” came to your clinic for advice about healthy eating and lifestyle. She is an editor of a shopping magazine and frequently reads articles about diets, nutrients, supplements, and healthy lifestyles. She found that much of the information she recently read is contradictory, which made her confused about what to eat and do. Her mother had type 2 diabetes and died at age 61 from a fatal myocardial infarction. The death of her mother at such young age compelled her to eat healthier and to walk for 30 minutes most days of the week.
She is now eating three regular meals per day and does not eat snacks. She tries to read all of her food labels and to keep her food intake to 1,800 calories per day. Although she dines out approximately 5 days per week, she controls her food portions as much as she can. She has maintained her weight for the last 5 years. She likes good wine and drinks 1-2 glasses when she dines out. She takes several over-the-counter supplements including vitamin D, calcium, magnesium, vitamin B12, and cinnamon. She does not have any gastro-intestinal symptoms, and she sleeps 6-7 hours every night. Recent results of lab work are below.
- Weight: 172 lbs
- Body mass index (BMI): 28 kg/m2 (normal, 18.5 to 24.9 kg/m2)
- Waist circumference: 32 inches
- Blood pressure: 124/72 mm Hg
- Serum low density lipoprotein cholesterol (LDL-C): 122 mg/dL (desirable, <100 mg/dL)
- Serum high density lipoprotein cholesterol (HDL-C): 39 mg/dL (desirable, ≥60 mg/dL)
- Serum triglycerides (TG): 280 mg/dL (desirable, <150 mg/dL)
- Fasting plasma glucose: 92 mg/dL (normal, 70-100 mg/dL)
- Glycated hemoglobin (HbA1c): 5.6% (normal, <5.7%)
She told you that she would like to follow a strict vegetarian dietary pattern since she heard that it is the best lifestyle. She would also like to follow a gluten-free diet to shed few pounds.