PBL3: The Struggle

Mr Phãstaphuda is a 42 year old Bangladeshi security guard, working a mix of day and night
shifts. He had his annual physical assessment at work, and was told that he had high blood
pressure and that he was overweight. It was recommended that he spoke to his GP about
further management of this.

There is a strong family history of diabetes, with both his older brothers treated with metformin,
and his sister treated with insulin for gestational diabetes during a recent pregnancy. His wife
says that he snores at night, and she worries that he may occasionally stop breathing. He tried
to diet many times but finds it way too difficult.

On clinical examination the GP notices Acanthosis Nigricans in his axillae bilaterally. His BP is
145/90mmHg. His height is 170cm, weight 85kg. His doctor agrees that his BMI puts him in the
“overweight” range, but cautions that this is not so accurate in South Asian individuals, and also
measures his waistline (96cm). She sends him for some blood tests, and arranges to see him
again with the results. The blood results are shown below:

Blood Results:  Parameters:  Value:  Normal range: 

Blood count  Haemoglobin (Hb)  156 130 to 170 g/L (male) 

Biochemistry Bilirubin 24 0-21 micromol/l

  Albumin  42 36 - 50 g/L  

Total protein 79 60 – 80 g/l

  Alanine aminotransferase (ALT) 60 < 40 unit/l 

  Alkaline phosphatase (ALP)  129 30 to 130 Units/L 

Total Cholesterol 4.0 < 5.0 mmol/l

LDL Cholesterol 1.3 < 3.0 mmol/l

HDL Cholesterol 0.7 0.9 – 1.45 mmol/l

Cholesterol:HDL ratio 5.7 <5

Triglycerides 4.32 <1.7 mmol/l

  Fasting glucose 6.1 3.5 – 5.6 mmol/l

 Haemoglobin A1c  46 < 48 mmol/mol 

She tells him that he has “pre-diabetes” and that an online calculator called QRisk2 estimates
his chance of having a stroke or a heart attack within the next 10 years as 7.5%. The doctor
reviews his liver function tests and suggests that he cut down on his alcohol intake, but he
assures her that he has never drunk any alcohol. She arranges an ultrasound scan of the liver
which demonstrates hepatic steatosis.

Mr Phãstaphuda is told that he has the “metabolic syndrome” and that the best way to manage
all these issues is for him to lose weight. He admits that he often comfort eats at home, and
while bored on night shifts often finds himself hungry and ordering fast food. He doesn’t have
the time or money to join a gym, and asks if there are any medicines he could take to help him
lose weight. "A magic pill would be great" he says. "Is there any kind of surgery I could get
maybe?" She refers him to a community dietitian, and advises him to download the EXI app for
his phone, to help him incorporate more exercise into his daily life. She explains that if he does
not make progress, there may be some additional treatments available via the obesity clinic at
the hospital, and describes a daily injection called Liraglutide, or a tablet called dapagliflozin.