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Kaitlyn is a 17-year-old girl with severe obesity who presents to the Healthy Weight Clinic for weight management. Her mother describes her as having been a thin child until the age of 7, when she developed pubic hair and began to gain excessive weight. Kaitlyn was diagnosed with Kallman syndrome at the age of 11, which does not allow her to have a period without medical intervention. She has been followed by Endocrinology for Kallman syndrome.

Kaitlyn has continued to gain weight despite multiple weight loss attempts—both medically supervised and unsupervised—and currently has a body mass index (BMI) of 41 kg/m2. As her weight has increased, she has developed insulin resistance, acanthosis nigricans, hypertriglyceridemia, and non-alcoholic fatty liver disease. Acanthosis nigricans is either a darkening or thickening of skin found around the neck and under the armpits that signifies the insulin is having to work harder to control blood sugar and, along with insulin resistance, is a precursor to type 2 diabetes. Insulin resistance, fatty liver disease, and high triglycerides are all a part of metabolic syndrome.

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Congratulations to Jen Cummings, DO, of Pittsburgh, Pennsylvania, who sent in the first correct answer to last issue’s challenge. The correct answer was id reaction, the topic of this issue’s cover story.