Medically supervised low-energy total diet replacement before staged arthroplasty in severe obesity and type 2 diabetes

ABSTRACT

Low-energy total diet replacement (TDR), when combined with medical monitoring, may support preoperative metabolic optimization in selected patients with severe obesity and type 2 diabetes (T2D). We report the case of a 57-year-old woman with severe obesity, type 2 diabetes, chronic prednisone exposure, obstructive sleep apnea, hypertension, and limited mobility who enrolled in a medically supervised total diet replacement (TDR) program to improve her candidacy for staged arthroplasty. At baseline, her weight was 312 lb (141.5 kg), her body mass index was 57.1 kg/m², and her hemoglobin A1c was 7.6%. The intensive phase provided approximately 960 kcal/day through formula-based meal replacement products and included weekly clinical visits, medication reconciliation, laboratory surveillance, electrocardiographic monitoring per clinic protocol, behavioral support, and perioperative dietary planning coordinated with the orthopedic team. Her weight decreased to 222 lb (100.7 kg), representing a 28.8% total body weight loss. Hemoglobin A1c decreased to 5.0%; lisinopril and potassium chloride were discontinued at week 5, and metformin was discontinued at 11 months. Hemoglobin A1c remained below 6.5% for at least 3 months after cessation of glucose-lowering therapy, meeting consensus criteria for T2D remission. The patient subsequently underwent staged left hip and right knee arthroplasty, with uncomplicated wound healing and no documented postoperative infection. This case illustrates a medically supervised, interdisciplinary pathway for high-risk arthroplasty candidates while emphasizing that findings from a single patient cannot establish causality or determine whether the intervention reduced perioperative risk.

Keywords: Preoperative Care; Diet, Reducing; Arthroplasty, Replacement; Diabetes Mellitus, Type 2; Weight Loss; Obesity, Morbid