Mrs. Smith, aged 55 years, came to the clinic to discuss her weight and options for losing weight. She says that during the last 10 years, she has had a steady weight gain regardless of what she eats or how much she exercises. She is concerned that a medical reason may be causing this weight gain.

Weight history

The patient’s lowest adult weight was 120 pounds. About 6 months ago, she was at her highest weight of 210. Her current weight is 201 pounds, with a BMI of 35.6.

Past medical history

  • Dyslipidemia, treated with simvastatin 20 mg
  • Hypertension, treated with metoprolol succinate 50 mg
  • Weight-bearing joint pain, specifically bilateral hips
  • Gastroesophageal reflux, treated with ranitidine 150 mg as needed
  • Snoring, per family member’s report
  • Family history of type 2 diabetes
  • No family history of Cushing’s disease or thyroid dysfunction

Past weight loss attempts

Several years ago, the patient tried Weight Watchers for a 6-month period. While she liked the accountability of Weight Watchers, she was unable to maintain the program due to its cost. She lost 15 pounds during the 6 months but regained the weight after stopping the program. She has tried multiple attempts at recording her food intake and exercise without much success. Recently, she tried NutriSystem and lost approximately 10 pounds. However, she did not believe it was a program that would work long term because she was eating only packaged foods from the company. She has not gained the weight back that she lost with NutriSystem.

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Pharmacotherapy for weight loss

She has tried orlistat and Dexatrim (OTC) in the past. She did not like the side effects of either of these medications and did not lose weight while taking them.

Current diet

The patient consumes 3 to 5 small meals per day. She tries to adhere to a diet of approximately 1,200 calories per day; however, she does not use a calorie-tracking tool. For breakfast, she usually has fruit with milk, oatmeal, an egg, or an English muffin. She has 1 piece of low-fat string cheese midmorning. For lunch, she typically has a salad with grilled chicken or a grilled chicken sandwich. She has an apple during the late afternoon. Her dinner consists of either chicken or fish and vegetables. She denies snacking after dinner.

She likes foods high in carbohydrates, and in the past, she has likely consumed more carbohydrates than she needs. She does not eat red meat and consumes minimal sweets. She drinks water, diet soda, and diet green tea. She also has two to three 6-ounce glasses of wine per week. She eats outside the home for approximately 3 lunches and 2 dinners per week. The lunches are at a specific restaurant where she is able to specify exactly how she would like something prepared. Dinners are at a variety of different restaurants.

Current activity

The patient reports that she often gets frustrated by her lack of weight loss and quits workout routines frequently. In the last month, she started walking on the treadmill at least a few times per week for 30 to 45 minutes per session.

Physical exam

  • General: Obese, not cushingoid. No acute distress.
  • Skin: No suspicious lesions, striae, hirsutism, or acne.
  • Thyroid: Symmetric, not enlarged, no nodules.
  • Breasts: Not examined.
  • Heart: Regular rhythm. No murmurs.
  • Lungs: Clear to auscultation.
  • Abdomen: Obese, nontender, nondistended, and normal bowel sounds. No masses, hepatosplenomegaly, or hernias.
  • Rectum: Not examined.
  • Genitalia: Not examined.
  • Joints: No crepitus or xanthoma.
  • Extremities: No edema or lymphedema.
  • Gait: Able to rise and walk without difficulty. Balance normal.
  • Mental: Normal orientation, judgment, and mood.
  • Last TSH: 1.0 mIU/L
  • Blood pressure: 119/70 mm Hg
  • Pulse: 65 bpm

Read the answer for Question 1.