The Man Who Couldn’t Stop Gaining Weight | A Medical Mystery

A previously healthy 21-year-old shows up with seven months of headaches and 30-plus pounds of weight gain he can’t explain. He’s eating the same and training more, and the scale climbs anyway. We hand the case to Dr. Austin Baraki cold and work it in real time: the exam, the labs, the MRI, and two diagnoses that turn a headache workup into the clearest proof we’ve got that body weight is set by the brain, not by character. This is the capstone of our weight series (willpower, calories, protein), and it ends on the drug that, this year, did something for these patients that nothing had done before.

Timestamps

00:00:00 Cold open: the man who couldn’t stop gaining weight00:01:49 Meet the case (and the rules of the game)00:02:36 The presentation: 21, headaches, unexplained weight gain00:03:57 Austin’s one-liner and how a clinician builds a differential00:05:10 Secondary headaches: what raises the red flag00:13:12 The exam: vitals, and the eye findings that matter00:14:37 The labs, one number at a time00:16:08 Raised pressure and a visual-field clue (bitemporal hemianopia)00:20:45 The MRI00:21:54 First diagnosis: craniopharyngioma00:25:32 The name: a tumor built from tooth tissue00:25:50 Surgery, and what it costs00:27:43 The new mystery: gaining weight faster than ever00:33:41 Second diagnosis: acquired hypothalamic obesity00:39:17 How your brain sets your weight: the POMC brake and the AgRP accelerator00:42:07 What about leptin?00:45:46 Monogenic vs common obesity00:50:30 Why GLP-1 drugs still worked: the brainstem backdoor00:52:11 Responders and non-responders00:55:40 Setmelanotide: a drug for the broken circuit00:56:53 TRANSCEND, and the new FDA approval00:58:55 What it costs01:01:32 Why we care about body fat at all: the garage01:04:36 Flux: which fat is actually dangerous01:09:15 Close

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1. Brijmohan A, et al. Acquired hypothalamic obesity following craniopharyngioma resection in a young adult [case report]. 2025. PMCID: PMC12268545; PMID: 40677794.

2. Miller JL, et al; TRANSCEND investigators. Setmelanotide in acquired hypothalamic obesity: a phase 3 randomized trial. N Engl J Med. 2026.

3. Rhythm Pharmaceuticals. FDA approves IMCIVREE (setmelanotide) for acquired hypothalamic obesity. News release. March 19, 2026.

4. US Food and Drug Administration. FDA approves first treatment for weight management for people with certain rare genetic conditions (setmelanotide). 2020.