• Clinical Crossroads

    So JAMA, one of the most prestigious medial journals in the world, has a feature called “Clinical Crossroads”. They will present a case, along with pertinent information, and then ask readers to write in, drawing on evidence from the literature as well as their experience, to recommend a diagnostic workup and therapy. Often, it will be a difficult case to diagnose, or one where therapeutic options force physicians to weight benefits and harms.

    Today’s though, is different. I don’t think the diagnosis is difficult. But what to do?

    CASE PRESENTATION

    Ms K is an obese 14-year-old girl who is struggling with weight loss. She lives in the greater metropolitan Boston area. Ms K began to gain weight at age 8 years. Over the past 7 years, her weight has gone up by 20 to 30 lb annually (Figure). Her peak weight is 256 lb, giving her a body mass index of 40. Her menarche was at age 11 years and her menstrual periods are regular. She reports trying various weight loss programs but either she did not follow through or they did not work. She has never lost more than 5 lb with any focused effort.

    On a typical day, Ms K skips breakfast, so her school lunch is her first meal of the day. She eats whatever is served there, often something “greasy,” with a small salad and chocolate milk. When she comes home from school, she begins to snack on “good” junk food. Over the course of the afternoon, she might have several of the following: baked chips, a cereal bar or 2, 2 or more “100-calorie packs,” a glass of (1%) milk, crackers, or pasta with cheese. She eats dinner with her parents, which is often fried chicken, pasta with cheese, or a hamburger. There are rarely vegetables on the plate. After dinner, she will routinely eat more, ingesting 1 to 3 snacks while working on her computer. She does not routinely eat dessert at dinner and does not drink sugar-sweetened beverages. She does not watch television regularly. She used to ride a horse several times a week but has not done so in several years. Her only regular activity is walking home from school, about mile daily.

    Ms K was told by her pediatrician that she needed to lose weight or she might develop diabetes. She has experienced harassment at school and online related to her obesity. There has also been significant tension between Ms K and her parents—especially her mother—about her eating habits and progressive weight gain.

    Ms K was adopted at birth. Her biological father is obese. Her adoptive parents are overweight. She does not drink alcohol, use recreational drugs, or smoke cigarettes.

    She has had no hospitalizations or surgery. On examination, Ms K weighs 248 lb and is 5 ft 6 in tall, giving her a body mass index of 40.2. Her blood pressure is 131/83 mm Hg, repeated at 118/70 mm Hg. The only other abnormal examination finding was dermatological changes on her neck, diagnosed as acanthosis nigricans.

    On the one hand, I’m pleased that JAMA is highlighting the fact that obesity is a clinical conundrum. On the other hand, I’m depressed by the fact that by the end of the case presentation, things look pretty hopeless. I’m eager to see what clinicians write in. The discussion will be published in the February 1 issue.

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    • Unfortunately, losing weight requires a consistent effort to burn more calories than one consumes, which is a very difficult thing to do with any regularity. The type of guidance a doctor can give is limited at best, considering how rarely the doctor sees the patient. Without consistent reinforcement of the message, it’s very difficult to change patient behavior.

      That being said, it’s not impossible. It is just important to involve family or friends to support the patient in that goal.