We describe the case of a 22-year-old South Asian male presenting to Endocrine Services with morbid obesity (BMI>50), sexual immaturity and agoraphobia. Born at full term following an uncomplicated pregnancy, he reached all developmental milestones appropriately. His problems began aged 15 after witnessing a murder, with reactive depression and hyperphagia. By the age of 18, he weighed over 140 kg, had poor self-image and suicidal ideation. He was managed initially by several multidisciplinary teams, including the Eating Disorders Psychologists, Psychiatrists and Dieticians, although the emphasis was on only his psychiatric condition with little communication between the specialties.
On referral to the Endocrine Service, he was clearly hypogonadal with a BMI of 64. Investigations confirmed hypogonadotrophic hypogonadism, (LH 1 IU/l, FSH 5 IU/l, Testosterone 0.6 nmol/l) with a normal karyotype. The remainder of his pituitary and adrenal function was normal. An MRI of the pituitary was also normal. His serum leptin was 63.4 ng/ml, insulin 116 pmol/l, pro-insulin 12 pmol/l and split pro-insulin 10 pmol/l.
Despite being known to several multidisciplinary teams for his co-morbidities, his weight continued to soar. He developed severe sleep apnoea, hypertension, arthritis and finally turned to heavy alcohol consumption.
It became clear that the only way forward was to establish organised communication between the teams. With diabetic education and anti-obesity medication he was able to lose 20 kg in weight. He was then referred to a tertiary Obesity Clinic weighing 177.6 kg (BMI 69). With organised contribution from all the specialties involved, a gastric banding procedure was eventually performed, resulting in a 12-month weight loss of 40.6 kg (BMI 53.5).
At 28 years of age, his management is currently shared by Endocrinology and Gastrointestinal Surgery. Plans for an jejunoileal bypass have been agreed with support from the Morbid Obesity team consisting of a Dietician, Psychologist, Consultant Physician, Psychiatrist and Fitness Instructor.
12 Dec 2008