Medically Supervised Low-Energy Total Diet Replacement Before Staged Arthroplasty in Severe Obesity and Type 2 Diabetes: A Case Report

Abstract

Low-energy total diet replacement (TDR), when paired with medical monitoring, may support preoperative metabolic optimization in selected patients with severe obesity and type 2 diabetes (T2D). We report a case of a 57-year-old woman with severe obesity, T2D, chronic prednisone exposure, obstructive sleep apnea, hypertension, and limited mobility who entered a medically supervised TDR program to improve candidacy for staged arthroplasty. Baseline weight was 312 lb (141.5 kg), body mass index was 57.1 kg/m², and hemoglobin A1c was 7.6%. The intensive phase prescribed approximately 960 kcal/day using formula-based meal replacement products, with weekly clinical visits, medication reconciliation, laboratory surveillance, electrocardiographic monitoring per clinic protocol, behavioral support, and perioperative diet planning coordinated with the orthopedic team. Weight decreased to 222 lb (100.7 kg), representing 28.8% total body weight loss. Hemoglobin A1c decreased to 5.0%, lisinopril and potassium chloride were discontinued at week five, and metformin was discontinued at 11 months. Hemoglobin A1c remained below 6.5% for at least three months after cessation of glucose-lowering therapy, meeting consensus criteria for T2D remission. The patient 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 single-patient findings cannot establish causality or determine whether the intervention reduced perioperative risk.