Abstract
Background Obesity in patients with autism is very prevalent. A third of the children with autism have a BMI above the 85th percentile, placing them at risk for developing obesity as adults. Obesity in the context of autism is likely more difficult to treat. Individuals with autism often demonstrate a preference for routine, which can lead to greater aversion to new tastes; also motor and social impairments may limit activities. People with autism are more likely to receive treatment with psychiatric medications, the majority of which cause weight gain. Under these circumstances, the treatment of obesity can become more challenging. Of importance, many individuals with intellectual/behavioral disabilities are denied bariatric surgery procedures due to their limitations in the ability to provide proper consent. We report here the successful use of anti-obesity medications followed by bariatric surgery in a young woman with autism and class 3 obesity, helping her lose 121 lbs and maintain her weight loss for more than 2 years. Clinical Case A 28-year-old female with autism and intellectual disability (IQ of 50), class 3 obesity (BMI 63.1 kg/m(2)), and depression presented for consideration of bariatric surgery. She weighed 391 lbs. A psychological assessment, found her to be an inappropriate candidate for surgery due to her intellectual difficulties limiting her ability to consent for surgery. Intense medical management for 18 months allowed the patient to lose 98 lbs with a subsequent weight plateau for another 8 months. At that point the patient’s family requested bariatric surgery to further assist with weight loss. A multidisciplinary evaluation was then performed by a committee involving members from psychology, nutrition, medicine, surgery, and bioethics. A joint decision was reached by all professionals involved to offer bariatric surgery to the patient (laparoscopic sleeve gastrectomy). The decision was based on the following facts: 1) Patient showed an ability to “assent” through a simplified understanding of the surgery and her goal “to become smaller”, 2) Patient was deemed likely to be able to adhere to post-operative protocols, 3) Patient had a strong family support (aptitude for responsible caretaking as all family members were trained as home caregivers). Upon follow-up 4 months post-bariatric surgery, the patient had lost an extra 32 lbs. Overall, her BMI had reduced from an initial 63 to 42 kg/m(2), and her weight was down to 270 lbs. Clinical Lessons The combination of anti-obesity medications followed by bariatric surgery may be a useful therapeutic approach for individuals with autism and severe obesity. Bariatric surgery seems to cause a reset of the cerebral set point reached after medical therapy. Special consideration should be given to individuals with cognitive impairments who have been successful losing weight with intense medical management and have strong family support.