If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.  

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A 40-year-old woman with obesity has made multiple attempts to lose weight for the past five years with no lasting success. She says she can’t resist sweets. She has, at times, lost up to 18 kilograms (40 pounds), which she has always regained. Her body mass index (BMI) is 42 kg/m2.

She is moderately hypertensive and is on a diuretic and an angiotensin-converting enzyme inhibitor. She has osteoarthritis of both knees. She also has severe obstructive sleep apnea and uses continuous positive airway pressure nightly during sleep.

Which of the following is the best option for her to achieve long-term weight loss and morbidity reduction?

A. Appetite suppressive medication.

B. Counseling aimed at reducing the underlying cause of her overeating.

C. Laparoscopic gastric band.

D. Low-fat diet.

E. Sleeve gastrectomy.

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The correct answer is E.

The patient has a BMI greater than 40 kg/m2 with several obesity-related medical comorbidities. She is an ideal candidate for bariatric surgery. A sleeve gastrectomy is one such procedure and can provide her with not only significant weight loss but also improvement of her comorbidities.

Choice A: Appetite suppressive medication is still something that is evolving and being actively developed, but it does not have the same effectiveness as surgery in achieving long term weight loss and risk reduction. The long-term safety of pharmacotherapy for weight loss is also not established.

Choice B: Counseling is most effective when it is intensive and combined with behavioral therapy. Counseling interventions can produce modest weight loss that is sustained for up to a year. This could be an adjunct to bariatric surgery to identify potential issues that cause overeating and help establish healthy lifestyle choices. However, it is unlikely to ensure long-lasting weight loss in this patient.

Choice C: Although popular in Europe, laparoscopic gastric band (LGB) has not been shown to be very effective in the American population, likely due to societal differences in eating habits. Sweets eaters, in particular, do poorly with LGB.

Choice D: Eating plans should be developed to reduce fats, concentrated carbohydrates, and large portion sizes, not just the level of fat in the diet. As noted, however, she has tried dieting in the past and has not had long-term success. Data shows that in this patient population, it is very uncommon to achieve long-term results.

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The following are indications for bariatric surgery:

  • Motivated patient.
  • BMI of more than 40 kg/m2.
  • BMI greater than 35 kg/m2 with serious comorbidities.
  • Reasonable surgical risk.
  • Failure of previous weight-loss regimens.

For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

The AMA selected Kaplan as a preferred provider to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. AMA members can save 30% on access to additional study resources, such as Kaplan’s Qbank and High-yield courses. Learn more.

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