Presentation

C.Y. is an obese 52-year-old white man with type 2 diabetes for 11 years, who is placed on a medically supervised weight-loss plan.

The plan begins with a 16-week medically directed weight-loss treatment that provides intensive skill-based lifestyle education and a nutritionally complete diet. The plan consists of at least 520 kcal/day using prepackaged products, vitamins, fiber, and ursodiol for prevention of gallstones. The patient sees the physician and nursing staff weekly in addition to attending the 1.5-hour behavioral education class. Patients are enrolled in maintenance classes after the initial 16 weeks of elective weight loss are completed.

Laboratory tests are performed at scheduled intervals throughout the program. At the start of the program, C.Y.'s physical examination and laboratory assays yielded the following data:

1. Height: 73.5 inches

2. Weight: 474.7 lb

3. BMI: 60.2 kg/m²

4. Hemoglobin A_1c (A1C): 6.7%

5. Triglycerides: 164 mg/dl

6. Total cholesterol: 167 mg/dl

7. LDL cholesterol, calculated: 102 mg/dl

8. HDL cholesterol: 34 mg/dl

9. Creatinine, serum: 1.1 mg/dl

10. Glucose, serum: 182 mg/dl

11. Blood pressure: 136/80 mmHg

At the start of the program, the patient's medications and supplements included:

1. Losartan/hydrochlorothiazide (HCTZ), 50/12.5 mg twice daily

2. Metoprolol extended release, 200 mg daily

3. Verapamil SR, 240 mg daily

4. Glyburide, 5 mg twice daily

5. Glyburide/metformin, 5/500 mg twice daily

6. Pioglitazone, 45 mg daily

7. Meloxicam, 7.5 mg daily

8. Ursodiol, 300 mg twice daily

C.Y. was diagnosed with hypertension in 1990, type 2 diabetes in 1993, and sleep apnea in 1995. He has a history of shortness of breath, pain in his knees because of arthritis, excessive …