Obesity Case 1

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.  


Question 1

Regarding her current lifestyle and her intentions to change it, which of the following is correct advice?

A. Drinking 1-2 glasses (5-10 ounces) of wine daily is beneficial, especially if it is a red wine.
B. A gluten-free diet, if precisely followed, will help you to reduce few pounds.
C. Go for a strict vegan diet since it will improve your health and provide you with all the nutrients that your body needs.
D. Reducing fat in your diet to <30% of total calories will help you to control your LDL-cholesterol and prevent cardiovascular disease.
E. Reduce your caloric intake by 250 calories and vary the type of exercise you do instead of just walking every 30 minutes every day.
Correct Answer
E. Reduce your caloric intake by 250 calories and vary the type of exercise you do instead of just walking every 30 minutes every day.

Alcohol, especially red wine increases HDL-C. If a person chooses to drink alcohol, the consumption must be moderate (no more than one drink a day for women and no more than two drinks a day for men). Additionally, it is not advisable that one actually increases alcohol consumption to these levels to derive a health benefit. One drink is equal to 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled alcohol. So, option A is incorrect as women should not exceed one drink per day.

Celiac disease or gluten sensitive enteropathy is an autoimmune disease in which there is an abnormal response to gluten, the protein contained in wheat, barley, and rye. Ingestion causes damage to the intestinal lining and malabsorption of micronutrients as well as varying degrees of symptoms, which may include diarrhea, bloating, weight loss, and fatigue. The treatment for celiac disease is a gluten-free diet. Some people without celiac disease report similar gastrointestinal symptoms when eating gluten-containing foods, although it is controversial whether these symptoms are due to the gluten itself. Regardless, gluten-free diets have become popular over the last few years, and many people are using them to lose weight. Some people lose weight because they end up eliminating high carbohydrate foods that they previously over consumed. Other people who choose to omit gluten replace gluten-containing carbohydrates with another type of carbohydrates like corn, rice, tapioca, and/or potato. In fact, many people on gluten-free diets gain weight. Since this patient does not have any gastrointestinal symptoms, she is unlikely to have gluten sensitivity. Thus, adopting a gluten-free diet is unnecessary, and option B is therefore incorrect.

A vegetarian eating plan is a relatively healthy eating pattern and has been associated with reductions in type 2 diabetes and cardiovascular risk in several observational studies. However, a strict vegan diet is associated with significant deficiency in many essential amino acids that only come from animal sources like milk, eggs, fish, meat, and poultry. If a person elects to follow a vegan diet, the diet should be supplemented with ketogenic essential amino acids to be balanced in nutrition. Therefore, option C is incorrect.

Due to the recognition of the benefit of “healthier” fats, restriction of dietary fat to Reducing daily caloric intake by 250-500 calories will help most people with overweight or obesity problems to lose weight. Since the patient in this case is overweight, a target BMI of 20-25 kg/m2may be advised to reduce her cardiovascular disease and type 2 diabetes risk. Regular physical activity, including a balanced mix of stretching, cardiovascular exercise, and progressive resistance exercise for at least 30 minutes most days of the week, has health benefits and is needed to control body weight. This new advice replaced the old recommendation of doing only aerobic exercise like walking 10,000 steps per day. Thus, option E is the correct answer.