To the Editor: I am concerned about a possible misrepresentation in the Journal. A recent Practice Essentials article included a case report describing the management of type 2 diabetes.1 The case involved a 51-year-old man with a 6-year history of type 2 diabetes and body mass index (BMI) of 32 kg/m2. The case report included a photograph, but this was not of a man with a BMI of 32 kg/m2. Ten consecutive professional staff working at a large Melbourne centre for bariatric (obesity) surgery were asked to estimate the man’s BMI. Estimates varied from 50 to 65 kg/m2. None accepted that his BMI was 32 kg/m2. All estimates placed this gentleman in the obesity class III category (BMI > 40 kg/m2). A man with a true BMI of 32 kg/m2 is shown in the Box.

If indeed the man depicted previously has class III obesity, he is likely to suffer significant obstructive sleep apnoea,2 physical disability and poor quality of life, in addition to the metabolic syndrome and type 2 diabetes. The case report focused on the management of an unacceptable level of glycosylated haemoglobin (HbA1c) of 8.9%. The management may, arguably, be appropriate if his BMI were 32 kg/m2, although treatment options may promote weight gain. Unfortunately, the options and discussion were inadequate for the man depicted.

This ill, disabled man deserves better assessment and care. His obesity-related conditions should be fully explored. The only management likely to have a significant effect on conditions related to class III obesity (diabetes, metabolic syndrome, sleep apnoea, physical disability and poor quality of life) is significant weight loss. The only treatment that reliably provides significant sustained weight loss for those with class III obesity is surgery. Obesity surgery therefore should be an essential inclusion in his treatment options. The beneficial effects of modern obesity surgery on type 2 diabetes, the metabolic syndrome, sleep and quality of life are well documented.3,4

I believe the inclusion of this illustration is a serious misrepresentation.

Editor's note: We agree with Dr Nixon's remarks, and have replaced the inappropriate illustration in the article with the image he has kindly supplied.

Patient with a body mass index of 32 kg/m2 (height, 172 cm; weight, 96 kg)