Eating disorders hard to treat

At age 20 years, my patient was diagnosed as having bulimia — less common in men than in women. His parents were wonderful and made certain that he went for therapy and a good result was achieved.

Unfortunately too good! When I saw him at age 40 years, he weighed in at 467 lbs. and he left the clinic only after I had made a referral to a very reputable weight loss program and he had scheduled an appointment. I have little doubt that he will keep that appointment. He specifically did not want to be considered for bariatric surgery but was convinced that with the right coaching he could lose the weight just as he had overcome bulimia. I am confident that he will, but just hope that he does not go too far in the other direction as he did before.

He was referred to me not for an eating disorder but because of low testosterone levels — not at all a surprising observation in the massively obese. He had been on testosterone replacement in the past but had stopped on his own accord despite the seemingly obvious benefits he derived. His major problem was a re-awakening of libido while he found himself in a situation where, because of his weight, there was not much he could do about it. After discussion he elected to forego testosterone replacement for now. That will make it a bit harder for him to convert fat to muscle but, even knowing that, it was his choice.

Why bring up this clinical anecdote? This is a highly educated, intelligent gentleman with a very responsible academic position. Yet he could not overcome his weight problems at either extreme of the spectrum despite interaction with skilled and reputable practitioners. Ongoing success for this patient will require almost lifelong intense care. “Cure” can be achieved in patients with eating disorders but it requires an understanding and expertise way beyond my skills — these patients must be referred to the appropriate colleagues!