Oliver Richards

BMI 21.3 is below the threshold of 27 (with comorbidity) or 30 (without). No qualifying comorbidities. Patient does not meet prescribing criteria for GLP-1 receptor agonists.

Patient is interested in GLP-1 medications after reading about them online. Wants to lose 5kg for aesthetic reasons.

Patient requesting semaglutide for cosmetic weight loss with BMI 21.3 — how to redirect to appropriate support?

Calorie counting app
Low-carb diet (4 months)
Increased running volume

[agent] Hello Oliver, welcome to your consultation today. I understand you're interested in discussing weight management options. Could you tell me a bit about what's prompted this?

[patient] Yeah, I've been reading a lot about Wegovy and Ozempic online, and a few of my mates have been using them. I just want to shift about 5 kilos — I've got a bit of a belly and I'd feel better about myself.

[agent] I appreciate you being open about that. It sounds like your confidence and how you feel about your body are important to you. Can I ask — have you noticed any health concerns related to your weight, or is this mainly about how you feel physically?

[patient] It's mostly how I look, to be honest. I'm pretty healthy otherwise. I run a few times a week and eat reasonably well. I just can't seem to shift this stubborn belly fat.

[agent] It's really positive that you're already active. Tell me a bit more about your running routine — how far do you typically go, and do you do any other types of exercise?

[patient] I usually run about 5K three times a week, sometimes a bit more at weekends. I used to do a bit of swimming but the pool near me closed down. I don't really do any weights or anything like that.

[agent] So you've got a solid cardio base there. That's genuinely impressive consistency. And what about your diet — you mentioned you eat reasonably well. What does a typical day look like for you?

[patient] I usually skip breakfast, grab a meal deal for lunch at work — sandwich, crisps, a drink — and then cook something in the evening. At weekends I cook properly, maybe a stir-fry or pasta. I have a few beers with mates on a Friday, nothing mad.

[agent] Thanks for walking me through that. Let me check a few things with you. Your BMI today is 21.3, which is actually well within the healthy weight range. You're 179cm and 68 kilos — does that sound about right?

[patient] Yeah, that's right. Is 21 not good enough then?

[agent] Actually, a BMI of 21.3 is right in the middle of the healthy range, which runs from 18.5 to 24.9. The medications you've been reading about — Wegovy and Ozempic — are specifically designed for people with a BMI of 30 or above, or 27 and above if they also have a weight-related health condition like diabetes or high blood pressure. At 21.3, you're well below both of those thresholds, so I wouldn't be able to prescribe them for you.

[patient] That's frustrating. My mate Jake got a prescription and he doesn't look much bigger than me. It feels like these criteria are a bit arbitrary. Can't you make an exception if I'm willing to pay privately?

[agent] I can understand that feels frustrating, especially when you see people around you getting these medications. The prescribing criteria aren't just about access — they're about safety. These medications work by significantly suppressing appetite and slowing gastric emptying. For someone at your weight, the risks of muscle loss, nutritional deficiency, and gastrointestinal side effects would outweigh any benefit. It wouldn't be safe or appropriate, even privately.

[patient] I get that, I suppose. It's just... I look at myself in the mirror and I see this belly and it really gets to me. Some days it's all I think about. I know it sounds stupid at my weight.

[agent] It doesn't sound stupid at all, and I'm glad you feel comfortable sharing that. Body dissatisfaction can affect anyone regardless of their weight, and it's something we take seriously. I notice you're already on sertraline for anxiety — have you ever spoken to your GP or a therapist specifically about how you feel about your body?

[patient] Not really. My anxiety is more general — work stress, that kind of thing. But yeah, the body image stuff has got worse since social media. Everyone's posting their before and afters with these injections and I feel like I'm missing out.

[agent] That's a really common experience, and social media can create a very distorted picture. Many of those transformation posts don't show the side effects, the muscle loss, or the weight regain when people stop the medication. For someone like you who's already healthy, the thing that would actually change how your body looks and feels is shifting the type of exercise you do. Can I explain what I mean?

[patient] Yeah, go on. I'm open to it.

[agent] Your blood sugar, cholesterol, and blood pressure are all excellent, so your health foundation is really strong. The belly fat you're describing is very common in men who do mainly cardio. Adding resistance training — weights, bodyweight exercises, that sort of thing — two to three times a week can genuinely transform your body composition. You'd build muscle, which increases your resting metabolism, and reduce that visceral fat around your middle. A lot of people find the scales don't change much but their shape changes dramatically.

[patient] Yeah, that would actually be helpful. I've been meaning to get into weights but I never know where to start. The gym is a bit intimidating to be honest.

[agent] That's a really common feeling. There are a few options — I could refer you to a fitness professional through our service who can put together a programme for you, or there are some excellent beginner strength programmes you can do at home with minimal equipment. I'd also suggest looking at your nutrition — skipping breakfast and relying on meal deals might mean you're not getting enough protein to support muscle building. A quick chat with a nutritionist could help too. What appeals to you?

[patient] The referral sounds good actually. And yeah, I probably should sort my diet out during the week. I eat well at weekends but Monday to Friday is a bit rubbish. Could I see a nutritionist as well?

[agent] Absolutely, I'll arrange both of those for you. I think with a structured strength programme, some tweaks to your weekday eating, and your existing running, you'll see real changes within a couple of months. And if those feelings about your body image continue to bother you, please do mention it to your GP — it might be worth exploring that alongside the anxiety management you're already doing. How does all of that sound?

[patient] That sounds like a proper plan, thanks. I appreciate you explaining why the medication isn't right for me rather than just saying no. And yeah, I'll think about the body image thing — maybe I should talk to someone about it.

Patient requested GLP-1 medication for cosmetic weight loss. BMI 21.3 is well within healthy range — does not meet prescribing criteria. Patient accepted explanation well and was redirected to resistance training and body composition strategies.

30-year-old male with BMI 21.3 requesting GLP-1 RA for cosmetic weight loss. Does not meet NICE or FDA criteria (BMI <27, no qualifying comorbidities). Anxiety disorder and IBS are managed. Healthy metabolic profile.

Oliver Richards is a 30-year-old software developer with a healthy BMI of 21.3 who is requesting GLP-1 medication after reading about it online. He has no obesity-related comorbidities — his anxiety and IBS are well-managed on sertraline. All metabolic markers are normal (HbA1c 5.2%, BP 118/72, cholesterol 4.8). He does not meet prescribing criteria for any GLP-1 receptor agonist and should be redirected to lifestyle-based body composition approaches.

Decline GLP-1 prescription — BMI 21.3 does not meet criteria. Redirect to strength training programme and dietitian if desired.

Hi Oliver, thanks for coming in today. I can see you're already doing well with your health — your weight, blood sugar, and blood pressure are all in a healthy range. The medications you've read about are designed for people with significantly higher weight who have health complications, so they wouldn't be appropriate for you. The great news is that adding some strength training to your running routine could really help with the body composition changes you're looking for. Would you like me to put together some guidance on that?

Patient enquired about GLP-1 medications for cosmetic weight loss. Agent assessed BMI at 21.3 (healthy range), explained prescribing criteria clearly, and the patient accepted the decision positively. Redirected to resistance training for body composition goals.

BMI 21.3 is well below the 27 threshold (with comorbidity) and 30 threshold (without). No T2DM, no cardiovascular disease, no obesity-related conditions. Patient's anxiety and IBS do not qualify as weight-related comorbidities. Clear ineligibility — no clinical ambiguity.

BMI 21.3 is within healthy range (18.5-24.9). No clinical indication for weight loss medication.

Well-controlled on sertraline 50mg. Not a weight-related comorbidity.

Patient reports anxiety managed
on sertraline since 2022

BMI 21.3 is well below both thresholds: 30 (without comorbidity) and 27 (with weight-related comorbidity). Patient's anxiety and IBS are not weight-related. Request is cosmetic/aesthetic, not medical.

Redirect to resistance training programme for body composition goals

Consider referral to registered dietitian for body recomposition nutrition plan

Review body image concerns — consider whether CBT could address underlying dissatisfaction

Clear ineligibility — no clinical ambiguity. BMI well below threshold with no weight-related comorbidities. Auto-process with clear redirection.

Structured meals, tends to skip breakfast, health-conscious but occasionally orders takeaway

No specific dietary preferences, enjoys cooking at weekends

Good access to supermarkets, lives near a food market

Snacks on crisps when gaming in evenings

Dark evenings in winter reduce outdoor running

Screen time before bed
Occasional anxiety-related waking

Work deadlines
Social media comparison
Relationship concerns

CBT - 6 sessions in 2023; Sertraline ongoing

Meditation app - occasional use; Running as stress relief

Reduce belly fat and improve muscle definition through strength training

Redirected from GLP-1 request to fitness-based approach

Manage body image anxiety through CBT techniques and exercise

Continuing sertraline, considering group therapy

Anxiety well-managed on sertraline
Weight stable at 67kg
BP normal

Continue sertraline 50mg
Review in 6 months

IBS symptoms worsened with work stress
Weight 68kg
Bloating and irregular bowel habits

Dietary advice for IBS
Consider low-FODMAP trial
Continue sertraline

Self-referred for GLP-1 medication enquiry

Motivated by aesthetic goals not medical need

Declined GLP-1 — does not meet criteria
Redirected to resistance training
Offered health coaching


Patricia Okafor

ABSOLUTE CONTRAINDICATION: Personal history of medullary thyroid carcinoma (MTC). All GLP-1 receptor agonists (semaglutide, liraglutide, tirzepatide) carry a black box warning against use in patients with personal or family history of MTC or MEN2.

Patient with T2DM and obesity was referred by GP for GLP-1 therapy consideration. Weight management is clinically indicated but GLP-1 RAs are absolutely contraindicated due to MTC history.

Patient has clear clinical need for weight management with T2DM and BMI 33.8, but has personal history of medullary thyroid carcinoma — what alternative weight management options are appropriate?

Walking programme — discontinued due to knee pain

[agent] Hello Patricia, thank you for joining today's consultation. I can see your GP has referred you to discuss weight management options. How are you feeling about that?

[patient] Well, my GP mentioned something called Wegovy — she said it might help with my weight and my diabetes at the same time. I've been struggling to get my sugars down and I've put on weight since I retired.

[agent] Retirement is a big life change. Could you tell me a bit more about how things have shifted since you stopped working? You were a nurse, weren't you?

[patient] Yes, I was a nurse for over 30 years. When I was working, I was on my feet all day — 12-hour shifts, running around the wards. Since I retired three years ago, I've slowed right down. I walk a bit, but it's nothing compared to what I used to do. The weight just crept on.

[agent] That makes a lot of sense — going from such an active role to retirement is a huge change in daily energy expenditure. You mentioned struggling with your blood sugars. Can you tell me how your diabetes has been managed recently?

[patient] My HbA1c was 7.8 at my last check, which my GP wasn't happy about. I'm on metformin and gliclazide, but the gliclazide seems to make me hungrier, which doesn't help with the weight. It's a vicious circle really.

[agent] You're absolutely right that it can feel like a vicious circle — some diabetes medications do increase appetite, and weight gain then makes the diabetes harder to control. I appreciate you explaining that. Before we discuss specific treatment options, I need to review your full medical history carefully. I can see you have diabetes, high blood pressure, high cholesterol, and stage 2 kidney disease. I also see a note about thyroid cancer. Could you tell me about that?

[patient] Yes, they found a lump in my thyroid back in 2019. I had a biopsy and it turned out to be medullary thyroid carcinoma — MTC, they called it. I had a total thyroidectomy and then some follow-up treatment. My endocrinologist says I'm in remission now, thank God. But they monitor me every six months still — calcitonin levels and scans.

[agent] I'm really glad to hear you're in remission, and it sounds like you're being well monitored. You mentioned something important in your records — your brother had a similar condition. Can you tell me more about that?

[patient] Yes, my brother Emeka was diagnosed with MEN2A a few years before me. That's actually how they caught mine early — they screened the whole family after his diagnosis. My children have been tested too. My eldest daughter carries the gene mutation, so she's being monitored closely. It's been very stressful for the family.

[agent] That sounds incredibly difficult — not just managing your own health but worrying about your children as well. You've shown real strength in dealing with all of this. I want to be thorough here because your thyroid history is directly relevant to the medication your GP suggested.

[agent] Patricia, I need to explain something important. Wegovy, and all the medications in its class — they're called GLP-1 receptor agonists, which includes semaglutide, liraglutide, and tirzepatide — carry what's called a black box warning for people with a personal or family history of medullary thyroid carcinoma. In animal studies, these drugs caused thyroid C-cell tumours, which is the same cell type involved in MTC. Because of your personal history of MTC and your family's MEN2A diagnosis, this entire class of medication is absolutely contraindicated for you. It's not a borderline case — it's a firm no.

[patient] Oh... I see. My GP probably didn't have the full picture when she referred me. She knows about the thyroid but maybe didn't connect it to these particular drugs. So there's genuinely nothing in this category that would be safe for me?

[agent] That's right — it applies to the whole class, not just one specific brand. Wegovy, Ozempic, Saxenda, Mounjaro — all of them work on similar receptors and all carry the same contraindication. I'll make sure your GP is fully aware so this doesn't come up again. I know it's disappointing when you were hoping for help.

[patient] It is disappointing. I watch the news and everyone's talking about these wonder drugs, and here I am — the one person who can't have them. With my diabetes, my weight, my knees... I really need something to help. It feels like I'm stuck.

[agent] I hear you, and that frustration is completely valid. But I want to reassure you — there are other options that can make a real difference, and some of them might actually be better suited to your overall health picture. Can I walk you through what we could consider instead?

[patient] Yes please. I really do want to get my weight down — my knees are suffering and I want to be able to play with my grandchildren properly.

[agent] That's a wonderful motivation. So there are a few avenues. First, for your diabetes and weight together, SGLT2 inhibitors like empagliflozin or dapagliflozin are excellent options. They work differently from GLP-1s — they help your body excrete excess glucose through urine, which leads to modest weight loss of around 2-4 kilograms. Importantly, they also protect your kidneys, which matters given your stage 2 CKD, and they reduce cardiovascular risk. They're very safe with your thyroid history.

[patient] That sounds promising. Would I be able to come off the gliclazide if I went on that? Because the gliclazide really does make me eat more.

[agent] That's a really good question, and it's something your GP and endocrinologist could work on together. Swapping gliclazide for an SGLT2 inhibitor could help with both the weight and the blood sugar, and remove that appetite-stimulating effect. Beyond medication, I'd also want to talk about a structured weight management programme — with your nursing background, you probably know more about nutrition than most patients, but having a formal plan and accountability can make a real difference.

[patient] You know, it's funny — I spent my whole career telling patients to eat well and exercise, and now I'm the one struggling. Since my husband passed and I retired, I've lost my routine. The church keeps me busy, but it's a lot of sitting and eating cake at fellowship.

[agent] Losing your husband and your professional routine at a similar time is an enormous amount of change. It's no wonder things shifted. And carrying the worry about your daughter's MEN2A screening on top of all that — you've had a lot on your plate. How is your daughter doing with the monitoring?

[patient] She's doing well so far — her calcitonin levels have been normal at every check. She's only 32, so they want to keep a close eye on her. She's actually been encouraging me to look after myself better. She says 'Mum, I need you around for a long time.' That's what got me to the GP about the weight.

[agent] Your daughter sounds like a wonderful source of motivation. Let me outline the next steps. I'll write to your GP recommending we explore the SGLT2 inhibitor option and review the gliclazide. I'll flag the GLP-1 contraindication clearly in your records. And I'd like to refer you to a structured weight management programme that includes dietary support and gentle exercise that's kind to your knees — things like swimming, chair-based exercises, or walking groups. Does that sound like something you'd be willing to try?

[patient] Yes, I'd like that. A walking group would be nice actually — I'd be more likely to go if there were other people involved. Thank you for explaining it all properly. I'd rather know the full picture than be given something that could bring the cancer back.

Patient referred by GP for GLP-1 therapy. Review identified absolute contraindication — personal history of medullary thyroid carcinoma (2019, thyroidectomy, in remission) with family history of MEN2A. Patient was informed clearly and accepted the decision. Redirected to SGLT2 inhibitor discussion and structured weight management programme.

metformin 1000mg BD
lisinopril 20mg
atorvastatin 40mg
gliclazide 80mg BD

T2DM
obesity
hypertension
MTC (resolved)
hyperlipidemia
CKD stage 2

57-year-old woman with T2DM (HbA1c 8.1%), BMI 33.8, hypertension, CKD stage 2. Would otherwise be an excellent GLP-1 RA candidate but has ABSOLUTE CONTRAINDICATION: personal history of medullary thyroid carcinoma (2019) and family history of MEN2A syndrome.

Patricia Okafor is a 57-year-old retired nurse with poorly controlled T2DM (HbA1c 8.1% on metformin + gliclazide), obesity (BMI 33.8), hypertension (142/88 on lisinopril), hyperlipidemia, and CKD stage 2 (eGFR 62). She was referred by her GP for GLP-1 therapy but has an absolute contraindication: personal history of medullary thyroid carcinoma (thyroidectomy 2019, now in remission) and family history of MEN2A (brother). All GLP-1 RAs are contraindicated. Consider SGLT2 inhibitor (empagliflozin — dual benefit for weight, glycaemia, and renal protection) and structured weight management.

DO NOT prescribe any GLP-1 receptor agonist — absolute contraindication (MTC history). Refer to endocrinology for SGLT2 inhibitor initiation and weight management plan. Flag GP records to prevent future GLP-1 prescribing.

Dear Patricia, thank you for today's consultation. After reviewing your full medical history, I need to let you know that the Wegovy medication your GP suggested isn't suitable for you because of your thyroid cancer history — these medications carry a specific safety concern for people in your situation. The good news is we have other effective options. I'd like to discuss a medication called empagliflozin, which can help with both your blood sugar and weight, and is also good for your kidneys. I'll write to your GP with my recommendations, and we can set up a follow-up to get started.

Patient referred for GLP-1 therapy but has absolute contraindication (personal MTC history + family MEN2A). Agent identified the contraindication, explained clearly, and redirected to SGLT2 inhibitor pathway. Patient was understanding and motivated to pursue alternative weight management.

MTC history is an absolute contraindication for all GLP-1 RAs (semaglutide, liraglutide, tirzepatide, dulaglutide). This is a black box warning, not a relative contraindication. Family history of MEN2A reinforces. Despite clear clinical need (T2DM + obesity + CKD), must redirect to alternative agents. SGLT2 inhibitors are the best alternative given dual glycaemic/weight/renal benefit.

HbA1c 8.1% on metformin 1g BD + gliclazide 80mg BD. Suboptimal control. Weight gain contributing. Consider SGLT2i addition.

Medullary thyroid carcinoma — in remission

Total thyroidectomy 2019, calcitonin undetectable at last check (Dec 2025). In remission. ABSOLUTE CONTRAINDICATION for all GLP-1 receptor agonists.

Thyroidectomy 2019
calcitonin undetectable
confirmed MEN2A

BMI 33.8 with T2DM and CKD stage 2. Clear clinical need for weight management but GLP-1 pathway blocked. SGLT2 inhibitor is best alternative — triple benefit (glycaemia + weight + renal protection).

BMI 33.8
weight 92.4kg
progressive weight gain over 3 years

eGFR 62, likely diabetic nephropathy. Stable but requires protection. SGLT2 inhibitors (empagliflozin/dapagliflozin) have proven renal benefits.

Absolute contraindication: personal history of medullary thyroid carcinoma. All GLP-1 RAs (semaglutide, liraglutide, tirzepatide, dulaglutide) carry black box warning against use in patients with personal or family history of MTC or MEN2. Patient also has confirmed MEN2A (brother affected). Despite clear clinical need (BMI 33.8, T2DM, CKD), this class is completely excluded.

Initiate empagliflozin 10mg OD — discuss with GP and endocrinologist

Structured weight management programme with dietitian

Flag GP records permanently: 'GLP-1 RA CONTRAINDICATED — MTC history'

Recheck HbA1c, renal function, and weight in 3 months

Continue annual MTC surveillance (calcitonin, endocrine follow-up)

Despite clear ineligibility (no ambiguity — black box contraindication), flagged for review because the patient has complex multi-system needs (T2DM + obesity + CKD + MTC history) requiring coordinated care planning across endocrinology, nephrology, and primary care.

Regular meals but large portions, comfort eating since retirement

Nigerian and British cuisine, enjoys cooking for family

Good access, shops at local market and supermarket

Nigerian cooking traditions — palm oil, starchy roots, large communal meals

Large portion sizes ingrained culturally

Church social events centred around food

Difficulty reducing starchy carbohydrates

Bilateral knee pain limits walking distance

Activity decreased over last 6 months due to worsening knee pain

Nocturia from diabetes
Anxiety about health
Knee pain at night

Worry about youngest daughter's employment

Church community and prayer
Cooking for family
Phone calls with sisters in Nigeria

Bereavement counselling — 2021 (husband passed 2020)

Church attendance twice weekly; Regular family gatherings

Lose 10kg through diet and alternative medication (non-GLP-1) within 12 months

GLP-1 contraindicated due to MTC history. Exploring SGLT2 inhibitor pathway.

Achieve HbA1c below 7.5% within 6 months

Currently 8.1% on metformin + gliclazide. May need SGLT2i addition.

Stabilise eGFR above 60 and prevent CKD progression

eGFR 62, stage 2 CKD. SGLT2i would provide dual glycaemic/renal benefit.

Medullary thyroid carcinoma — total thyroidectomy

2.3cm medullary thyroid carcinoma
Calcitonin elevated
No lymph node involvement

Total thyroidectomy performed
Started levothyroxine replacement
6-monthly calcitonin monitoring
Genetic testing confirmed MEN2A

eGFR 65
Likely diabetic nephropathy early stage
Urine ACR mildly elevated

Diagnosed CKD stage 2
Optimise BP and glycaemic control
Annual renal monitoring

HbA1c 7.8% — above target
Weight 90.1kg
BP 140/86
eGFR 64

Increased gliclazide to 80mg BD
Dietary advice reinforced
Renal review in 6 months

MTC surveillance — annual calcitonin check

Calcitonin undetectable — consistent with remission

Continue annual surveillance
Next calcitonin in December 2026

GP referral for weight management medication

BMI 33.8 — would normally qualify for GLP-1

ABSOLUTE CONTRAINDICATION: personal MTC history

Declined GLP-1 — black box contraindication


Daniel Kowalski

BMI 27.2 with hypertension and prediabetes. Meets the BMI ≥27 with comorbidity threshold marginally. Lifestyle intervention should be attempted first per NICE guidelines. GLP-1 RA could be considered if 3-6 months of lifestyle changes fail to achieve 5% weight loss.

Patient concerned about weight gain over last 2 years, family history of diabetes and heart disease. GP suggested exploring medication options after lifestyle advice alone hasn't worked.

With BMI 27.2, prediabetes, and hypertension — is the patient at the threshold for GLP-1 initiation, or should structured lifestyle intervention be trialled first?

Low-carb diet (3 months, 2024)
Walking more — inconsistent
Reduced alcohol — temporary

[agent] Hello Daniel, welcome. I understand you'd like to discuss some options for weight management. Can you tell me what's been on your mind?

[patient] Yeah, I've been putting on weight steadily over the last couple of years. Desk job, no time to exercise with two young kids. My dad had a heart attack at 62 and got diabetes at 55, so I'm worried I'm heading the same way.

[agent] That's a really understandable concern, and it's good that you're being proactive. Your family history is something we should take seriously. Can I ask what you've tried so far in terms of diet or exercise?

[patient] I tried cutting carbs for a few months last year but it was hard to sustain with the family. My wife does most of the cooking and she makes a lot of Polish food — pierogi, potatoes, bread — it's what we both grew up with. I walk to the station some days instead of driving, but that's only about 15 minutes. My GP put me on blood pressure tablets in June and my last blood test showed my blood sugar is creeping up.

[agent] It sounds like there are quite a few things pulling at you at once — work, family, the commute. Tell me a bit more about a typical working day for you. What does it look like from morning to evening?

[patient] I'm up at half six, out the door by seven. The commute is about an hour and a half each way — drive to the station, train into Manchester, then walk to the office. I'm at my desk by nine, don't really move until lunch. Lunch is usually a sandwich from Tesco. Then back at the desk until five or six. By the time I get home at half seven, the kids need bathing and putting to bed. I collapse on the sofa and that's my evening.

[agent] That's a really long day. Three hours of commuting, nine hours at a desk, and then parenting in the evening — there's not much left for you in there, is there? And I imagine the snacking at work fills a gap when you don't have a proper lunch break?

[patient] Exactly. The biscuit tin comes out in every meeting, and I just pick at them without thinking. Tax season is the worst — January to April I'm practically living on coffee and whatever's in the vending machine. That's when the weight really piles on.

[agent] I can see how that pattern builds up. Let me share where your numbers are at the moment. Your HbA1c is 6.2%, which puts you in the prediabetes range. Your BMI is 27.2 — you've gone from 85.7 kilos when you registered to 88.5 now. And with your blood pressure requiring medication, you're in what we'd call a borderline zone for GLP-1 medications like Wegovy.

[patient] Borderline? So I might qualify?

[agent] It's a clinical judgement call. The guidelines say BMI 27 or above with a weight-related health condition can qualify. You meet that technically — but you're right at the threshold. Most clinicians would want to see a structured lifestyle programme tried first for 3 to 6 months before starting medication. The evidence is strong that lifestyle changes at your stage can prevent progression to full diabetes.

[patient] I'm willing to try, but honestly I've been saying that for two years and the weight keeps going up. With my dad's history I feel like I don't have time to waste.

[agent] Your concern about your father's history is completely legitimate. A first-degree relative with type 2 diabetes and cardiovascular disease does significantly increase your own risk. Your father had his heart attack at 62 — you're 43 now, which means we have a window to change your trajectory. How old was he when he started having health problems?

[patient] He was probably my age, maybe a bit younger, when he started getting the blood pressure issues. The diabetes came at 55, and then the heart attack at 62. He's still alive but he's on about ten different medications and he can't do much. I don't want to end up like that. My kids are 7 and 10 — I want to be around for them.

[agent] That's a powerful motivation, Daniel. Let me propose something concrete. Rather than a vague 'try to eat better and move more,' I want to set specific, measurable goals for the next three months. If we hit them, great — you may not even need medication. If we don't, we have a documented case for starting GLP-1 therapy without any delay. Does that sound reasonable?

[patient] Three months I can do. But I need it to be realistic — I can't suddenly become someone who goes to the gym at 5am.

[agent] Absolutely — it has to fit your life. For diet, I'd suggest three things. First, swap the meal deal for something with more protein and less processed carbs — even a supermarket salad with chicken. Second, bring your own snacks to meetings so you're not reaching for biscuits — nuts, fruit, that sort of thing. Third, work with your wife on the weekend meals — Polish food can be really nutritious, it's just about adjusting portions and maybe adding more vegetables alongside the pierogi. How does that feel?

[patient] The lunch swap I can definitely do. The snacks thing too. The family meals... my wife's actually been saying she wants us to eat healthier since my blood test results came back. She was worried. So she'd probably be on board with that.

[agent] That's great that your wife is supportive — having someone on your side at home makes a real difference. For exercise, I'd keep it simple. You're already walking to the station some days — can you commit to doing that every day? That's 30 minutes of walking built into your routine with no extra time needed. And at weekends, one family activity that gets you moving — park with the kids, a bike ride, a swim. Nothing that takes you away from the family.

[patient] Walking to the station every day is doable. The weekend thing too — the kids would love it actually. My son's been asking me to take him cycling.

[agent] Perfect. Now, the monitoring side. I want you to keep a rough food diary — nothing obsessive, just a note of what you eat each day on your phone. Weigh yourself once a week, same time, same day. And I'd like you to check your blood pressure at home — your GP can lend you a monitor, or they're about twenty pounds from a chemist. We'll recheck your HbA1c and weight at the three-month mark. The target is 3 to 4 kilos of weight loss.

[patient] And if I don't hit that target, we go straight to medication? I don't want to be fobbed off with another three months of 'try harder.'

[agent] Absolutely — I'll document this plan clearly with the specific targets, so there's no ambiguity at the three-month review. If you've made genuine effort and the numbers haven't moved, we have a strong case for starting medication and there'll be no delay. I'll also flag your family history in the referral. We'll recheck your blood sugar, blood pressure, weight, and waist circumference at the review.

[patient] Right, I'm going to actually do this properly. I'll talk to my wife tonight about the food, and I'll start walking to the station tomorrow. My dad didn't have this kind of warning — I do, and I'd be stupid to ignore it.

[agent] That's a really positive attitude, Daniel. You've clearly thought about this and you've got strong motivation with your family. I'll send you a summary of everything we discussed today, and we'll schedule that three-month follow-up. If anything changes before then — if your weight goes up significantly or you feel unwell — don't wait, get in touch. Take care.

[patient] Thank you. I actually feel like I've got a plan now, not just someone telling me to lose weight. I appreciate it.

Patient with BMI 27.2, prediabetes, and hypertension is borderline eligible for GLP-1 therapy. Strong family history of T2DM and cardiovascular disease adds clinical urgency. Agreed on 3-month structured lifestyle intervention with clear escalation pathway to medication if insufficient weight loss.

43-year-old male, BMI 27.2, prediabetes (HbA1c 6.2%), hypertension on amlodipine. Technically meets BMI ≥27 + comorbidity threshold but is marginal. Strong family history of T2DM and CVD. Lifestyle intervention first, with clear 3-month review and escalation pathway.

Daniel Kowalski is a 43-year-old accountant with a BMI of 27.2, newly diagnosed prediabetes (HbA1c 6.2%, fasting glucose 6.4), and hypertension managed with amlodipine. He has a concerning family history — father developed T2DM at 55 and had an MI at 62. His BMI marginally meets the ≥27 with comorbidity threshold for GLP-1 therapy, but given no prior structured lifestyle intervention, NICE guidelines favour a 3-6 month trial of diet and exercise first. A clear escalation plan should be documented.

Initiate structured lifestyle programme with dietitian referral. Schedule 3-month review with repeat HbA1c, weight, and BP. If <3% weight loss at review, escalate to GLP-1 RA prescription.

Hi Daniel, thanks for an honest and helpful conversation today. Given your weight, blood sugar levels, and family history, I want to take a proactive approach. You're in a borderline zone for weight management medication — you could qualify, but guidelines suggest trying a structured lifestyle plan first. Here's what I'd like to do: set you up with a proper dietary plan and some realistic exercise targets for the next 3 months. If the weight isn't shifting by then, we'll move straight to medication — no delays. I'll also recheck your blood sugar and blood pressure at that point. Does that work for you?

Patient presented with BMI 27.2, prediabetes, and hypertension. Family history significant for T2DM and early CVD. Borderline GLP-1 eligibility discussed transparently. Agreed on 3-month structured lifestyle intervention with clear escalation criteria documented.

BMI 27.2 is just above the 27 threshold. Prediabetes and hypertension qualify as weight-related comorbidities. However, no prior structured lifestyle intervention has been attempted, and NICE NG28 recommends non-pharmacological approaches first for patients at the lower BMI threshold. Family history adds clinical urgency but doesn't change the guidelines threshold. Borderline — reasonable clinicians could disagree.

HbA1c 6.2%, fasting glucose 6.4 mmol/L. Progressive trend from 5.8% in 2024. Strong family history of T2DM (father dx age 55). Weight gain trajectory increases conversion risk.

HbA1c 6.2%
fasting glucose 6.4
father T2DM at 55

BMI 27.2, steady gain from 85.7 to 88.5 kg over 20 months (+2.8kg). Sedentary occupation and lifestyle are primary drivers. Marginal for GLP-1 eligibility.

Weight timeline shows consistent upward trend

BP 138/86 on amlodipine 5mg. Suboptimal control. Weight loss would likely improve BP and potentially allow medication reduction.

BMI 27.2 marginally meets the ≥27 threshold with comorbidities (prediabetes + hypertension). However, no structured lifestyle intervention has been attempted. NICE guidelines recommend lifestyle first at the lower BMI threshold. Family history adds clinical urgency but doesn't change the threshold. Recommend 3-month lifestyle trial with documented escalation pathway.

Semaglutide (Wegovy) — if lifestyle intervention fails at 3 months

Initiate 3-month structured lifestyle programme with dietitian

Set clear targets: ≥3% weight loss and HbA1c improvement at 3-month review

If targets not met, initiate Wegovy 0.25mg without further delay

Recheck HbA1c, fasting glucose, lipids, and BP at 3-month review

Consider cardiovascular risk scoring (QRISK3) given family history

Borderline eligibility requires senior clinical review. Clinical case is reasonable but guidelines favour lifestyle first. Document the escalation pathway to avoid delay if lifestyle fails.

Eats well at home but relies on sandwiches and coffee at work, portion sizes increasing

Polish home cooking at weekends, British during the week

Good access, suburban area with supermarkets nearby

Polish family meals tend to be carbohydrate-heavy (pierogi, potatoes, bread)

Desk-bound job with no lunch break routine

Snacking on biscuits during afternoon meetings

Weekend family meals are large and carb-heavy

Too tired to meal prep after long commute

Long commute (1.5 hours each way)
Desk job — sits 9 hours/day
Young children leave little free time
No gym membership

Walking to station some days instead of driving — started 2 months ago

Children waking at night occasionally
Work stress
Late screen time

Tax season workload
Father's health decline
Mortgage concerns
Childcare juggling

Football on TV
Beer with friends (monthly)
DIY projects

Dr. M. Hussain, Didsbury Medical Practice

Lose 5% body weight (4.4kg) through structured lifestyle programme within 3 months

Starting structured programme. If <3% loss at 3 months, escalate to GLP-1.

Reverse prediabetes — achieve HbA1c below 5.7%

HbA1c 6.2%, fasting glucose 6.4. Lifestyle first, medication if needed.

Reduce 10-year cardiovascular risk through weight loss and BP control

Father had MI at 62. Patient motivated by family history.

BMI 26.5
BP 134/82 — borderline elevated
Fasting glucose 5.8 — normal high

Lifestyle advice
Repeat BP in 3 months
Baseline bloods ordered

BP 138/86 — confirmed hypertension
Weight 86kg, BMI 26.5

Started amlodipine 5mg
Dietary and exercise advice
Review in 3 months

Annual review — hypertension and prediabetes monitoring

HbA1c 6.0% — prediabetes confirmed
Weight 87.2kg, BMI 26.9
BP 136/84 on amlodipine

NHS Diabetes Prevention Programme referral

GP referral for weight management assessment — prediabetes and hypertension

Prediabetes + hypertension qualify as comorbidities

No prior structured lifestyle intervention completed

Borderline eligibility — lifestyle intervention first


Helen Nguyen

Long-term PPI use (3.5+ years) — associated with B12 malabsorption. Current B12 185 pg/mL (low-normal). Consider step-down or supplementation.

limited - on feet at work but no structured exercise

Occupational only — no structured exercise

Melatonin

Sleep onset difficulty with sleep apnoea

BMI 26.8 is below the 27 threshold by 0.2 points. However, sleep apnoea is a weight-sensitive condition that could benefit from even modest weight loss. NICE guidelines allow clinical discretion for patients near the threshold with weight-sensitive comorbidities. Borderline — requires senior clinical review.

Patient has obstructive sleep apnoea that is significantly impacting her quality of life and depression. Weight loss of 5-8% could improve both conditions. CPAP compliance is poor due to discomfort.

BMI 26.8 with sleep apnoea and depression — is there sufficient clinical justification for GLP-1 therapy below the standard 27 threshold, given the weight-sensitive nature of OSA?

Portion control — difficult with restaurant work

Walking programme — couldn't sustain due to fatigue

No formal weight management programme attempted

[agent] Hello Helen, welcome. I understand you're here to discuss weight management and how it might help with some of your other health conditions. Could you tell me what's been most concerning for you?

[patient] Honestly, it's the sleep. I was diagnosed with sleep apnoea last year and they gave me a CPAP machine but I just can't get on with it. I wake up more tired than when I went to bed. My mood has been terrible — I'm running a restaurant on four hours' sleep.

[agent] Four hours of sleep is really difficult to sustain, especially with the physical demands of running a restaurant. Can you tell me a bit more about what happened with the CPAP? What specifically didn't work for you?

[patient] The mask was horrible. I tried two different ones — the nasal one and the full face one. Both of them made me feel claustrophobic and I kept pulling them off in my sleep. The noise bothered me too. I gave it three weeks and just couldn't do it anymore. The sleep clinic said I could try a mandibular device but I haven't got round to it.

[agent] That sounds really frustrating, especially when you were trying to do the right thing. Your AHI of 22 events per hour is moderate sleep apnoea, so treatment is important. Tell me about your work schedule — I know running a restaurant involves unusual hours.

[patient] I'm usually at the restaurant by 10 in the morning for prep and deliveries. Lunch service runs until 3, then there's a bit of a break, then evening service from 5 until we close at 10 or 11. By the time I've cashed up and cleaned down, it's midnight. Then I can't switch off — my mind's still going. I probably don't fall asleep until 1 or 2.

[agent] That's an incredibly demanding schedule. Sleep apnoea on top of those hours must be exhausting. Your GP notes mention you've been on sertraline since November 2023 for depression — has that helped at all?

[patient] A bit. I don't feel as low as I did last winter, but I still feel flat and exhausted all the time. I think the root of it is the sleep. I used to have loads of energy — I could do a double shift no problem. Now I'm dragging myself through every service.

[agent] You mentioned your energy has changed. When did you start noticing the weight creeping up? And — if you don't mind me asking — where are you at with menopause? That can have a significant impact on weight and sleep.

[patient] I started going through perimenopause about two years ago — hot flushes, mood swings, the lot. That's when the weight started going on. I went from about 66 kilos to 72 in about 18 months. My mum was the same — she put weight on after menopause and ended up with diabetes by 60.

[agent] That's really helpful context. So perimenopause, sleep apnoea, depression, and the restaurant hours are all feeding into each other. The weight gain worsened the sleep apnoea, the poor sleep worsened the depression and fatigue, and the fatigue makes it almost impossible to make changes. It's a cycle that's hard to break without some help.

[patient] That's exactly it. My GP said if I lost some weight it might help the apnoea. That's why I'm looking into these weight loss injections. I feel like I need something to break the cycle.

[agent] Your GP is right — even a 5-8% weight loss can significantly improve sleep apnoea. In your case that would be about 4 to 6 kilograms. Your current BMI is 26.8, which is just below the usual threshold of 27 for GLP-1 medications. It's a borderline situation.

[patient] So I'm 0.2 away from qualifying? That seems a bit arbitrary when my sleep apnoea is making me miserable.

[agent] You raise a fair point. The thresholds are guidelines, not absolute rules, and your situation is exactly the kind of case where clinical judgement matters. Sleep apnoea is a weight-sensitive condition, your CPAP tolerance is poor, and the downstream impact on your depression and ability to function is significant. There's a reasonable clinical argument for GLP-1 therapy here. Before we go further though, I want to understand your eating patterns. Restaurant work must make it tricky to eat regular meals.

[patient] I usually have a coffee in the morning, nothing else. Then the staff meal is around 3pm — it's whatever we've prepped, usually something from the menu. Then I might pick at things during evening service — a spring roll here, some rice there. I eat again when I get home at midnight, usually something quick. So I'm eating twice, both times late in the day.

[agent] That pattern of late eating is really common in hospitality, and it's not helping your GERD either — eating close to lying down makes reflux worse. Speaking of which, I notice you're on omeprazole. Long-term omeprazole use can reduce vitamin B12 absorption, and low B12 can cause fatigue, low mood, and cognitive fog — which would compound everything else you're experiencing. I see you started B12 supplements recently. We should check your levels at your next blood test to make sure they're adequate.

[patient] I didn't realise the omeprazole could be making me more tired. So what happens with the weight medication? Can you prescribe it or does someone else need to decide?

[agent] I'd like to flag this for a senior clinician review, because it is a borderline decision. I think there's a reasonable clinical case — moderate sleep apnoea with CPAP intolerance, the impact on your mental health, the perimenopausal weight gain, and your family history of diabetes and obesity. In the meantime, there are some things we can start working on. I'd encourage you to go back to the sleep clinic about that mandibular device — it's much less intrusive than CPAP. Could you also try moving that late-night meal to before 10pm? And a 20-minute walk during that afternoon gap between services could help both your sleep and your mood.

[patient] The walk I can try — there's a park near the restaurant. Moving the evening meal earlier is harder because service doesn't finish until 10 or 11, but maybe I could eat something proper at 9 during a quiet moment rather than waiting until I get home. The mandibular device... I'll call the clinic. I just haven't had the energy to chase it up.

[agent] Those are really sensible adjustments that work with your schedule rather than against it. One more thing — how are you doing emotionally beyond the tiredness? Running a restaurant as a single parent, dealing with all these health issues... that's a lot to carry.

[patient] Honestly, I don't have time for therapy, if that's what you're suggesting. My daughter helps at the restaurant sometimes, which is nice, but she's got her own life too. I think if the sleep improved, a lot of the other stuff would follow. I just need one thing to get better first.

[agent] I understand that completely, and I agree — fixing the sleep could be the domino that starts everything else moving. I'll aim to have the GLP-1 review done within a week. I'll also make a referral back to the sleep clinic for the mandibular device. And we'll check your B12 levels and do a general blood panel to make sure nothing else is being missed.

[patient] That sounds good. I'll try the walk and the earlier eating. Thank you for not just dismissing me because of a number. I was worried you'd just say 'lose weight' and send me away.

[agent] Not at all — your situation is complex and it deserves a thoughtful approach. I'll be in touch once the review is done. And Helen — please do try to be kind to yourself. You're managing an enormous amount and you're still showing up every day. That counts for a lot.

[patient] Thank you. It's been a while since someone actually listened to the whole picture. I'll start with that walk tomorrow.

Patient with BMI 26.8 and obstructive sleep apnoea (CPAP-intolerant) seeking GLP-1 therapy. Depression significantly impacted by poor sleep. Borderline eligibility — BMI 0.2 below threshold but clinical case exists due to weight-sensitive OSA. Flagged for senior clinical review. Also noted low B12 (185 pg/mL) on long-term omeprazole.

overweight
obstructive sleep apnoea
GERD
depression

50-year-old woman, BMI 26.8, with obstructive sleep apnoea (CPAP-intolerant), depression, and GERD. BMI marginally below 27 threshold. Weight loss would directly benefit OSA and mood. Low B12 on long-term omeprazole — being supplemented.

Helen Nguyen is a 50-year-old restaurant owner with BMI 26.8 (0.2 below threshold), obstructive sleep apnoea with CPAP intolerance, depression on sertraline, and GERD on omeprazole. Her sleep apnoea is severely impacting quality of life and mood, and even modest weight loss (5-8%) could provide clinically meaningful improvement. CPAP intolerance makes weight management the primary therapeutic avenue for OSA. B12 is low at 185 pg/mL — expected with long-term PPI use, supplementation started. This is a genuine borderline case where clinical discretion is warranted.

Escalate to senior clinician for borderline eligibility decision. Clinical case: CPAP-intolerant OSA + depression make weight management medically urgent despite BMI 26.8. Monitor B12 levels — recheck in 3 months.

Hi Helen, thank you for such an open conversation today. I can see how much the sleep apnoea is affecting your daily life and your mood, and I take that very seriously. Your weight is just below the usual threshold for the medication you're interested in, but given your sleep condition and the difficulty with the CPAP machine, I think there's a good case to be made. I'm going to refer your case to a senior clinician for a decision — I expect to hear back within a week. In the meantime, try to fit in a short walk after lunch if you can — it helps with both sleep and mood. I've also noted your B12 is a bit low, so keep up with the supplements and we'll recheck that too.

Patient presented with sleep apnoea (CPAP-intolerant), depression, and BMI 26.8. Borderline GLP-1 eligibility discussed transparently. Clinical case made for weight loss as primary OSA therapy given CPAP failure. Flagged for senior review. B12 monitoring recommended on long-term PPI.

BMI 26.8 is 0.2 below the 27 threshold. Normally this would be a clear decline, but OSA is a strongly weight-sensitive condition where even small weight reductions can reduce AHI significantly. CPAP intolerance removes the primary non-pharmacological OSA treatment, making weight loss more clinically urgent. Depression is likely secondary to sleep deprivation. NICE allows clinical discretion near thresholds when comorbidities are weight-sensitive. Low confidence on eligibility (0.55) reflects genuine clinical ambiguity — this needs senior review.

Obstructive sleep apnoea — moderate, CPAP-intolerant

AHI 22, moderate severity. CPAP abandoned after 3 weeks due to intolerance (3 mask types tried). Weight loss is now the primary therapeutic pathway. Even 5-8% loss could reduce AHI significantly.

Sleep study AHI 22
CPAP usage <2h/night
discontinued Feb 2024

PHQ-9 was 16 at diagnosis. On sertraline 100mg with partial response. Chronic sleep deprivation (4.5 hours, poor quality) is likely the primary driver. Treating OSA should improve depression.

PHQ-9 16
sertraline 100mg
4.5h sleep/night

B12 185 pg/mL (low-normal). On omeprazole 20mg since Jul 2022 (3.5 years). Long-term PPI use reduces B12 absorption. Supplementation started — recheck in 3 months.

B12 185 pg/mL — below optimal range (200-900 pg/mL)

Omeprazole 20mg daily since July 2022 (3.5+ years continuous use)

PPIs reduce gastric acid → impair B12 absorption from food

Patient reports fatigue and low mood — both associated with B12 deficiency

NICE CKS recommends B12 monitoring for PPI use >12 months

B12 deficiency causes fatigue and neuropsychiatric symptoms that overlap with depression. Correcting B12 may improve mood, energy, and treatment engagement — important before attributing all symptoms to depression or OSA. GLP-1 agonists can worsen GI symptoms; PPI step-down should be cautious if GLP-1 initiated.

Borderline overweight with weight-sensitive comorbidity

BMI 26.8, 0.2 below the 27 threshold. However, OSA is strongly weight-sensitive and CPAP (primary treatment) has failed. Weight loss becomes medically necessary, not just desirable. Clinical case for GLP-1 exists despite sub-threshold BMI.

BMI 26.8
CPAP-intolerant OSA
gradual weight gain trend

BMI 26.8 is 0.2 below the standard 27 threshold. OSA is a weight-sensitive comorbidity where even modest weight loss can meaningfully reduce disease severity. CPAP failure eliminates the primary non-pharmacological treatment, making weight management more clinically urgent. NICE guidelines allow clinical discretion near thresholds for weight-sensitive conditions. This is a genuine borderline case requiring senior clinical judgement.

Semaglutide (Wegovy) — if senior review approves

Omeprazole (long-term PPI) → Vitamin B12 malabsorption: B12 185 pg/mL (low-normal). Consider B12 supplementation or PPI step-down if GERD controlled.

Recheck Vitamin B12 in 3 months — if declining, start IM B12 or oral supplementation

Monitor weight and BMI monthly during lifestyle trial period

Repeat sleep study if weight loss >5% to reassess OSA severity

PHQ-9 reassessment at 6 weeks — sertraline dose review if no improvement

Review omeprazole necessity — trial PPI step-down to lansoprazole 15mg or on-demand use

If GLP-1 approved: start Wegovy 0.25mg, with repeat sleep study at 3 months to measure AHI change

If GLP-1 declined: refer for mandibular advancement device and structured weight management

Recheck vitamin B12 in 3 months — consider omeprazole step-down if GERD allows

Review sertraline dose if sleep improves — depression may resolve with better sleep

Borderline eligibility with clinical complexity — CPAP-intolerant OSA makes weight loss medically urgent, not just desirable. Sub-threshold BMI requires senior sign-off. Low confidence on eligibility (0.55) reflects genuine clinical ambiguity.

Irregular meals due to restaurant hours, eats staff meal at 3pm and late at 10pm

Vietnamese cuisine, enjoys cooking but doesn't cook for herself — always cooking for the restaurant

Surrounded by food all day but eats whatever is convenient, not what's healthy

Vietnamese food culture — rice-based, smaller portions traditionally but Westernised menu at restaurant

Eats only 2 meals — both late in the day

Constant proximity to food at work leads to grazing

Too exhausted to cook separately for herself

Restaurant portions are large (Western-adapted menu)

Daily — 8-10 hours standing/walking in kitchen

No time or energy for structured exercise outside work

Fatigue from sleep apnoea has reduced even occupational activity — sitting more during shifts

Obstructive sleep apnoea — AHI 22 events/hour

CPAP intolerance — abandoned after 3 weeks

Works until 10-11pm, can't fall asleep until 1am

Restaurant business pressures — rising costs, staff shortages

Cooking (both therapy and source of stress)

Occasional phone calls with sister in Vietnam

Sertraline 100mg since Nov 2023; GP counselling referral — waiting list

Melatonin for sleep onset; Cooking as mindfulness

Lose 5-8% body weight to improve sleep apnoea severity

Borderline GLP-1 eligibility — awaiting senior review. Weight loss is primary treatment pathway for OSA given CPAP failure.

Reduce AHI from 22 to below 15 through weight loss and positional therapy

CPAP abandoned. Mandibular advancement device being considered.

Improve depression symptoms through better sleep and sertraline optimisation

Depression likely secondary to chronic sleep deprivation. Treating sleep should improve mood.

Classic GERD symptoms
No red flags
BMI 25.9

Started omeprazole 20mg
Dietary advice — avoid late eating
Review if not improved

Low mood, fatigue, difficulty concentrating

PHQ-9 score 16 — moderate depression
Poor sleep reported
Weight 70.5kg, BMI 26.2

Started sertraline 50mg
Sleep hygiene advice
Counselling referral submitted
Review in 4 weeks

Partial response to sertraline 50mg
Still waking unrefreshed
Snoring reported by daughter

Referred to sleep clinic for suspected sleep apnoea

Home sleep study: AHI 22 events/hour — moderate OSA

BMI 26.5 — positional and anatomical factors

CPAP trial initiated
Sleep hygiene counselling
Weight management discussion

CPAP usage <2 hours/night
Reports mask discomfort, claustrophobia
No improvement in daytime sleepiness

Tried 3 mask types — all poorly tolerated

Weight loss emphasised as key intervention

Self-referred for weight management — sleep apnoea not improving

BMI 26.8 — 0.2 below threshold
OSA moderate, CPAP-intolerant
Depression on treatment
Low B12 on long-term PPI

Borderline eligibility — flagged for senior review