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Endocrine obesity guidelines

ESC publishes endocrine work-up in obesity guidelines

• Thyroid-Stimulating Hormone (TSH) screening is recommended in patients with severe obesity before bariatric surgery

European Society of Endocrinology has published guidelines recommending testing for all patients with obesity for thyroid function (given the high prevalence of hypothyroidism in obesity). The comprehensive guidelines also recommend hormonal testing for hypercortisolism, male hypogonadism and female gonadal dysfunction, only in cases of clinical suspicion of an underlying endocrine disorder.

The present European Society of Endocrinology Clinical Guideline is focused on the endocrine work-up in patients with obesity. Although not its main focus, the guidelines do discuss the potential therapeutic consequences of hormonal alterations in patients with obesity, but do not to focus on syndromic obesity.

The overall purpose of the guidelines is to provide clinicians with practical guidance for the endocrine work-up in obesity. In clinical practice, diagnostic – and treatment decisions should take into account the recommendations but also the clinical judgment of the treating physician. Recommendations are thus never meant to replace clinical judgment.

The guidelines state that obesity is an emerging condition, with a prevalence of ~20% and although the simple measurement of BMI is likely a simplistic approach to obesity (BMI is easily calculated), there are currently no data showing that more sophisticated methods are more useful to guide the endocrine work-up in obesity. An increased BMI leads to several hormonal changes. The guidelines “underlines that weight loss in obesity should be emphasised as key to restoration of hormonal imbalances and that treatment and that the effect of treating endocrine disorders on weight loss is only modest.”

The guidelines, ‘European Society of Endocrinology Clinical Practice Guideline: Endocrine work-up in obesity’, published in European Journal of Endocrinology, recommend that not all patients with obesity are routinely referred to an endocrinologist and that hormonal evaluation should take into account and dietary supplements that interfere with hormone measurements.

Bariatric surgery

Specifically, the guidelines making several recommendations and findings for patients undergoing bariatric surgery, including;

  • Further reasons for referral to the endocrinologist include therapy-resistant obesity and /or rapid weight gain and candidates for bariatric surgery
  • Thyroid-Stimulating Hormone (TSH) screening is recommended in patients with severe obesity before bariatric surgery
  • Abnormal thyroid function usually improves after weight loss obtained by calorie restriction or by bariatric surgery suggesting that in obesity the increase in serum TSH (in the absence of thyroid autoantibodies) is likely an adaptive response rather than the primary event. Therefore, hyperthyrotropinaemia associated with obesity must be differentiated from auto-immune-related subclinical hypothyroidism.
  • Structural changes of the thyroid have also been associated with obesity including increases in thyroid volume and hypoechogenicity as well as thyroid nodules, which may be due to increased TSH stimulation or increase in inflammatory mediators produced by the adipose tissue. The improvement of thyroid hypoechogenicity after bariatric surgery argues for this hypothesis.
  • In patients going for bariatric surgery (testing for) hypercortisolism should be considered because these patients commonly present with obesity-related comorbidities such as hypertension, metabolic syndrome and type 2 diabetes, which are also frequent in Cushing’s Syndrome. Some bariatric candidates may have endogenous hypercortisolism that could lead to severe adverse effects after surgery if undiagnosed and hypercoagulability, catabolic state and increased cardiovascular risk may be responsible for severe postoperative complications, making this scenario especially sensible for CS detection.
  • An exception for routine measurement of 25OHD and PTH should be made for patients with obesity submitted to bariatric procedures.

The guidelines were developed for healthcare providers involved in the care of patients with obesity, which covers a broad range of doctors, although the guidelines were not developed with the specific aim to cover rare forms of obesity.

To access the guidelines, please click here

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