Weight loss/diabetes counselling

Question 1

A 48 year old male taxi driver sees you for his mild type 2 diabetes. He weighs 128kg, his BP is 122/74mmHg and BSL 19mmol/L. He says he can’t lose weight despite eating nothing. How would you counsel him?

Answer 1

Introductory
Salient features of the stem are BSL of 19 indicating poorly controlled T2DM, along with several risk factors for metabolic syndrome including overweightedness, sedentary lifestyle, poor diet.

Would consider other causes of metabolic syndrome including;

• endocrine: Cushing syndrome
• medications:
• congenital: leptin deficiency

In this case my priorities are;

1 - assessing (Hx/Ex/Ix) for complications of diabetes, profiling his absolute CVD risk and
2 - counselling about diabetes management and weight loss, as well as ideal diet
3 - appropriate referral to relevant allied health for input, any relevant medications and escalation to his diabetes management plan and ?meds for weight loss

Question 2

Weightloss/diabetes counselling - History

Answer 2

History

• PC: what exactly is ‘eating nothing’, fast foods? saturated fats, processed meals etc.
• diabetes sx: polyuria, polydipsia, polyphagia, visual change, sensory/motor changes (lower limbs)
• CVD risk factors: HTN, obesity, sedentary, smoking, alcohol, fam hx, other CVD
• current medications, allergies. any A/E?
• PMHx, PSHx
• SNAP
• readiness for change

Question 3

Weight loss/diabetes counselling - Examination

Answer 3

Examination

• General appearance + vitals
• anthropometrics
• cardiovascular examination
• fundoscopy
• peripheral neuropathy assessment (sensory, motor,

Question 4

Weight loss/diabetes counselling - Investigations

Answer 4

Investigations
Key
- Fasting lipids, BSL, HbA1C, etc
- urinalysis, uACR

Other

• Bloods: UEC, LFT
• nil imaging indicated
• calculate absolute CVD risk

Question 5

Weight loss/diabetes counselling - Management

Answer 5

Management

• Engage MDT, GP referral and follow-up
• Appropriate review period
• screening for complications

Diabetes
Non-pharm
- lifestyle changes: exercise, smoking, alcohol
- diabetes educator, dietary counselling (reduce saturated fats)
- referrals for ophthalmology/endocrine if required
- regular review intervals
Pharm
- metformin
- SGLT2/GLP1 receptor analogue, Liraglutide, (also good for weight loss;

Weight-loss
Non-pharm
- same as above lifestyle factors
Pharm
- appetite suppressants: phentermine (sympathomimetic), not for use in anxiety, or established CVD
- reduced absorption of gastric lipids: Orlistat
- GLP-1 analogues: liraglutide
Surgical 
- bariatric surgery