Obesity Case 8

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.

Question 1

  Which of the following is the most appropriate next step?

A. Referral for a treadmill nuclear stress test
B. Measure total testosterone
C. Add lisinopril to his medication regimen
D. Referral to a dietitian
E. Start phentermine
Correct Answer
A. Referral for a treadmill nuclear stress test

Overweight and obesity represent a continuum of a chronic disease that takes away from psychological, physical (adiposity), and metabolic (adiposopathy) health. The initial approach to a patient with overweight or obesity involves risk stratification. A thorough evaluation looking for causes or complications of the increased fat mass is the goal of the first patient encounter. Many of the complications of obesity generate vicious cycles that make ongoing accrual of fat mass likely and loss of fat mass difficult. These complications include insulin resistance, male hypogonadism, sleep apnea, depression, degenerative disc disease, and degenerative osteoarthritis.

Additionally, pharmacotherapy may cause the accumulation of fat mass or become an obstacle to weight loss. A careful review of medications is needed to remove the ones that may cause weight gain and introduce alternatives that may lead to weight loss. This patient is treated with a beta blocker. Beta blockers cause chronotropic insufficiency, depression, exacerbation of reactive airway disease, erectile dysfunction, and because of all of this, weight gain. Replacing the beta blocker with other antihypertensive medications is desirable in this patient, unless he already has coronary artery disease.  This patient has dysmetabolic syndrome, with hyperglycemia, hypertension, high triglycerides, low HDL-C, and a high waist circumference, which places the patient at high risk of coronary artery disease. Therefore, an assessment of the patient's coronary artery reserve is the most important first step before making therapeutic decisions.Measuring the patient's total testosterone is appropriate since many of the patient's symptoms may be due to hypogonadism. These symptoms include fatigue, loss of libido, erectile dysfunction, and depression.

A low total testosterone needs further laboratory evaluation to determine whether the patient has primary hypogonadism or hypogonadotropic hypogonadism. A total testosterone of 200 ng/dL or less warrants treatment with testosterone replacement as a means to help the weight loss process.If the patient does not have established coronary artery disease, beta-blocker therapy may be discontinued. Treatment of the patient's hypertension is medically necessary. Angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the preferred agents to treat hypertension in patients with obesity. Lisinopril should be added when atenolol is discontinued.The cornerstones of good health include meal planning, healthy eating, good nutrition, adequate daily physical activity, adequate sleep, and time for recreation. Referral to a dietician is always appropriate to help patients meet these goals.