Obesity and Metabolic Syndrome

What is the weight status of a patient whose BMI is 32.3 kg/m²?

• Normal

• Overweight

• Obese Class 1

• Obese Class 2

Answer explanation

A BMI of 30 or above would be categorized as obese. A BMI between 30-35 would be categorized as obese class 1. 35-40 would be obese class 2. Normal weight (BMI 18.5-25) is not the correct answer. Overweight (BMI 25-30) is also not correct.

PW is a 57 YO male with asthma, HTN, and anxiety. His medications include fluoxetine 20 mg PO daily, Symbicort 180-4.5 mcg 2 puffs BID and PRN and amlodipine 10 mg PO daily. Fasting labs are shown in the image. Vital signs: 122/78 mmHg, waist circumference 35 inches.

Does this patient meet the diagnostic criteria for metabolic syndrome? Why or why not?

Answer explanation

Yes, this patient meets 4 of the 5 diagnosis criteria for metabolic syndrome. 3 of 5 criteria are required for diagnosis.

His waist circumference is not elevated, but his triglycerides are elevated (>150), his HDL is low (<40), and his fasting glucose is elevated (>100). Lastly, his BP is normal BUT he is on an anti-hypertensive treatment.

Weight loss medications can be prescribed for patients with a BMI >30 kg/m² OR a BMI > (a)   kg/m² with at least one weight-related comorbidity.

Which is the most likely side effect of phentermine?

• Increased BP

• Hepatotoxicity

• Drowsiness

• Bradycardia

Answer explanation

Cardiac effects such as increased blood pressure, arrhythmias, and increased heart rate are commonly associated with phentermine. Insomnia (not drowsiness) is associated with phentermine as well.

Which weight loss medication is contraindicated in patients with a history of seizures?

• Phentermine-topiramate

• Semaglutide

• Orlistat

• Naltrexone-bupropion

Answer explanation

Naltrexone-bupropion (Contrave) is contraindicated in patients with history of seizures because of the bupropion component.

Which medication has a black box warning for thyroid c-cell tumor?

• Naltrexone-bupropion

• Phentermine

• Liraglutide

• Orlistat

Answer explanation

GLP-1 agonists (including liraglutide and semaglutide) have this black box warning. They are therefore contraindicated in patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia.

MC is a 40 YO male interested in weight loss medications. He has tried changing his diet and exercising with minimal success. His BMI is 32 kg/m2. PMH includes T2DM (last A1c 7.5%) and HTN (last BP 154/82 mmHg).

Which weight loss medication(s) would be appropriate for MC? Select all that apply.

• Orlistat

• Semaglutide

• Phentermine

• Phentermine-topiramate

Answer explanation

The only inappropriate option is phentermine due to its effects on increasing BP and this patient has uncontrolled HTN. The rest of the options are safe as they will not increase BP or glucose levels. Of note, semaglutide is associated with the largest amount of weight loss and is the best option since it will also treat his diabetes.

What is an appropriate weight loss goal for a patient with a BMI of 40 kg/m2, current weight of 300 lbs?

Answer explanation

15-45 lbs over the next 6-12 months would be acceptable answers. This would be 5-15% of the patient's baseline weight. The timeline is an important component of this answer as well - note that answers on exams/quizzes without a time frame will be marked incorrect.

Which weight loss medication is administered multiple times a day with high fat meals?

• Orlistat

• Phentermine

• Liraglutide

• Tirzepatide

Answer explanation

Orlistat works by reducing fat absorption through inhibiting GI lipase. It should be taken PO TID within 1 hour of consuming a meal containing fat. Patients can skip a dose if a meal is skipped or if it contains no fat.

Which weight loss medication(s) can increase heart rate? Select all that apply.

• Naltrexone-bupropion

• Orlistat

• Phentermine-topiramate

• Liraglutide