Weight Management Practice Exam: Diabetes Chapter 17

Obesity is a significant risk factor for the development of type 2 diabetes and complications in both type 1 and type 2 diabetes. The 2018 Clinical Practice Guidelines emphasize that weight management is not merely an aesthetic goal but a primary therapeutic target to improve glycemic control and cardiovascular health.

This practice exam tests your ability to apply the evidence-based recommendations for behavioural, pharmacological, and surgical weight management interventions.

Key Concepts Covered in This Exam:

Therapeutic Targets: Understanding that a sustained weight loss of $\ge$ 5% of initial body weight can significantly improve glycemic control and cardiovascular risk factors.
Intervention Hierarchy: Recognizing healthy behaviour interventions as the cornerstone of treatment, to be maintained even when medications or surgery are added.
Pharmacotherapy: Identifying the role of specific weight management medications for individuals with diabetes and obesity to improve metabolic control.
Surgical Options: Knowing the indications for bariatric surgery and its potential to induce diabetes remission or significant improvement.
Medication Selection: Applying the principle that the effect on body weight must be considered when selecting antihyperglycemic agents, prioritizing those with weight-loss or weight-neutral properties.

1. What are the effects of moderate carbohydrate reduction in people with diabetes regarding weight management?

Increased risk of hypoglycemia only
No metabolic benefits
Worsening of lipid profile
Improvements in HDL and triglycerides, blood glucose stability, and reductions in diabetes medication requirements

2. Which of the following two medications are approved for chronic weight management in Canada?

Orlistat and liraglutide
Metformin and sitagliptin
Canagliflozin and dulaglutide
Empagliflozin and exenatide

3. Case: A 52-year-old patient with type 2 diabetes has a BMI of 32 kg/m², A1C=7.3%, and is currently on glyburide and metformin. The patient is struggling with weight. What antihyperglycemic medication consideration is most appropriate?

Add pioglitazone for additional glycemic control
Consider switching from glyburide to an agent not associated with weight gain
Add insulin to improve glycemic control
Half the glyburide dose

4. Case: A patient with type 2 diabetes is being considered for bariatric surgery. What effect has bariatric surgery been shown to have on diabetic nephropathy?

Bariatric surgery is contraindicated in patients with nephropathy
Bariatric surgery worsens albuminuria
Bariatric surgery can prevent the development and progression of albuminuria
Bariatric surgery has no effect on kidney function

5. Which antihyperglycemic medication class is associated with the most weight gain?

DPP-4 inhibitors
Insulin
SGLT2 inhibitors
Metformin

6. What psychological aspects of eating behaviours should be assessed when determining reasons for weight gain?

Emotional eating, binge eating, ADHD, and depression
Exercise habits only
Sleep patterns only
Medication adherence only

7. A diabetes educator is reviewing the evidence on bariatric surgery and diabetes remission. What is important to communicate to patients who experience remission?

People may experience recurrence of diabetes years later
Remission is permanent and no follow-up is needed
Medications should continue indefinitely regardless of remission
No dietary modifications are needed after surgery

8. Case: A patient with type 2 diabetes has been on intensive insulin therapy and has gained significant weight. According to the guidelines, what is the weight gain range associated with some antihyperglycemic medications?

1 to 2 kg
10 to 15 kg
2 to 3 kg
4 to 9 kg or more

9. Case: A 45-year-old patient with type 2 diabetes, BMI 29 kg/m², has tried healthy behaviour interventions without success. The patient is asking about weight management medications. What BMI threshold is required for pharmacotherapy in people with type 2 diabetes?

BMI ≥30.0 kg/m²
BMI ≥35.0 kg/m²
BMI ≥27.0 kg/m²
BMI ≥25.0 kg/m²

10. What has been shown regarding the increase in obesity prevalence in people with type 1 diabetes over the last 20 years?

Threefold increase
Fivefold increase
Twofold increase
Sevenfold increase

11. What percentage of people with type 2 diabetes have overweight or obesity?

60% to 70%
50% to 60%
80% to 90%
70% to 80%

12. Case: A 58-year-old patient with type 2 diabetes, BMI 42 kg/m², has been unsuccessful with healthy behaviour interventions and pharmacotherapy. Which bariatric surgery procedure has been largely abandoned in North America?

Biliopancreatic diversion
Roux-en-Y gastric bypass
Gastric band
Sleeve gastrectomy

13. Which interventions combined are most effective at improving health outcomes in weight management?

Physical activity alone
Dietary modification alone
Medication therapy alone
Dietary modification, increased physical activity, and behaviour therapy

14. Case: A patient with type 1 diabetes and obesity is asking about weight management medications. What does the evidence say about pharmacotherapy for weight management in type 1 diabetes?

Liraglutide 3.0 mg is approved for type 1 diabetes
Orlistat is specifically indicated for type 1 diabetes
Pharmacotherapy directed at weight management has not been adequately studied in people with type 1 diabetes
All weight management medications are contraindicated in type 1 diabetes

15. What are the NCEP-ATP III waist circumference cut-off values indicating increased risk of developing health problems?

Men ≥102 cm; Women ≥88 cm
Men ≥94 cm; Women ≥80 cm
Men ≥90 cm; Women ≥80 cm
Men ≥100 cm; Women ≥90 cm

16. What is the mechanism of action of liraglutide in weight management?

Increases glucose excretion through the kidneys
Increases satiety and decreases hunger in the brain
Blocks carbohydrate absorption
Decreases fat absorption in the intestine

17. Which of the following antihyperglycemic medications are considered weight neutral?

GLP-1 receptor agonists and SGLT2 inhibitors
Insulin and sulfonylureas
Metformin, acarbose, and DPP-4 inhibitors
Thiazolidinediones and insulin

18. What has been demonstrated about the comparison of people with obesity and diabetes versus those without diabetes when attempting weight loss?

People with diabetes should not normally attempt weight loss
People with diabetes lose weight more easily
There is no difference between the groups
People with obesity and diabetes have greater difficulty achieving weight loss

19. What negative energy balance is needed to achieve a weight loss of 2 to 4 kg per month?

Approximately 500 kcal/day
Approximately 1000 kcal/day
Approximately 750 kcal/day
Approximately 250 kcal/day

20. Case: A patient is being considered for bariatric surgery. What type of team should evaluate candidacy and appropriateness for surgical procedures?

Endocrinologist and dietitian
Surgeon only
Primary care provider only
Interdisciplinary team with medical, surgical, psychiatric, and nutritional expertise

21. What is the typical weight loss associated with SGLT2 inhibitors?

2 to 3 kg
5 to 7 kg
8 to 10 kg
0 to 1 kg

22. What is the BMI threshold for Class II obesity?

27.0 to 29.9 kg/m²
30.0 to 34.9 kg/m²
≥40.0 kg/m²
35.0 to 39.9 kg/m²

23. Case: A diabetes educator is reviewing the checklist for evaluating weight management programs. Which of the following is NOT part of the recommended checklist?

Cost is not prohibitive
Access to a weight maintenance program
Requirement to buy specific products, supplements, or injections
The program assesses and treats comorbid conditions

24. Case: A diabetes educator is counselling a patient about weight management programs. According to the guidelines, what is a reasonable weight loss goal per month?

3 to 4 kg/month
0.5 to 1 kg/month
5 to 6 kg/month
1 to 2 kg/month

25. According to Health Canada guidelines, what measurements should be included in the initial assessment of people with diabetes?

Height, weight, and grip strength
Height and weight only
Height, weight, calculation of BMI, and waist circumference
Weight and waist circumference only

26. What is the typical weight loss associated with liraglutide in people with diabetes?

About 5 kg
About 1 kg
About 10 kg
About 3 kg

27. At what BMI threshold is bariatric surgery a treatment option for people with type 2 diabetes who have comorbidities?

BMI ≥30.0 kg/m²
BMI ≥40.0 kg/m²
BMI ≥45.0 kg/m²
BMI ≥35.0 kg/m²

28. What are the waist circumference cut-off values for South Asian, Chinese, and Japanese populations indicating central obesity?

Men ≥102 cm; Women ≥88 cm
Men ≥90 cm; Women ≥80 cm
Men ≥85 cm; Women ≥75 cm
Men ≥94 cm; Women ≥80 cm

29. Why was the gastric band largely abandoned in North America?

Too expensive compared to other procedures
Excessive weight loss
Lack of qualified surgeons
Less sustained weight loss and metabolic benefits, and high surgical complication rates

30. Case: A patient with type 2 diabetes and obesity is started on a weight loss program and begins losing weight. What medication adjustment may be required?

Add additional insulin to maintain glycemic control
No medication changes are needed during weight loss
Increase antihyperglycemic medications to prevent weight regain
Adjustment of antihyperglycemic medications may be required to avoid hypoglycemia

31. What are the rare potential complications of liraglutide treatment for weight management?

Liver failure and kidney damage
Gallbladder disease and acute pancreatitis
Cardiovascular events and stroke
Hypoglycemia and weight gain

32. Case: A clinical team is evaluating a patient for bariatric surgery. What are the predictors of likelihood of remission of type 2 diabetes after bariatric surgery?

Use of oral medications only
Higher preoperative C-peptide, younger age, shorter duration of diabetes, and no insulin therapy
Lower preoperative C-peptide, older age, and longer duration of diabetes
Higher BMI

33. Case: A patient with obesity and impaired glucose tolerance (IGT) is asking about medications to prevent progression to type 2 diabetes. Which weight management medication has been shown to improve glucose tolerance and reduce progression to type 2 diabetes?

Orlistat
Sulfonylureas
Metformin
Insulin

34. Which bariatric surgery procedures have the highest likelihood of improvement in control or remission of type 2 diabetes?

Gastric banding
Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion
Intragastric balloon
All procedures have equal outcomes

35. What are the potential adverse effects of orlistat that may affect long-term compliance?

Nausea and vomiting
Hypoglycemia
Loose stools and gastrointestinal side effects
Weight gain

36. Case: A clinician is considering the metabolic effects of bariatric surgery beyond weight loss. What has been shown about bariatric surgery and cardiovascular outcomes?

Cardiovascular outcomes have not been studied
Bariatric surgery may reduce the risk of myocardial infarction in people with type 2 diabetes
Bariatric surgery has no effect on cardiovascular outcomes
Bariatric surgery increases cardiovascular risk

37. What is the minimum sustained weight loss of initial body weight that can improve glycemic control and cardiovascular risk factors?

≥15%
≥2%
≥10%
≥5%

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