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Probability diagnosis

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Exogenous obesity

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Alcohol excess

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Fluid/oedema

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Drugs

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Genetic polymorphisms

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Serious disorders not to be missed

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Cardiovascular:

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  • cardiac failure

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Hypothalamic disorders (hyperphagia):

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  • craniopharyngiomas

  • optic gliomas

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Insulinoma

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Liver failure

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Nephrotic syndrome

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Pitfalls (often missed)

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Pregnancy (early)

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Postmenopause

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Endocrine disorders:

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  • hypothyroidism

  • Cushing syndrome

  • insulinoma

  • acromegaly

  • hypogonadism

  • hyperprolactinaemia

  • polycystic ovarian disease

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Idiopathic oedema syndrome

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Klinefelter syndrome

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Congenital disorders:

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  • Prader–Willi syndrome

  • Laurence–Moon–Biedl syndrome

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Masquerades checklist

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Depression

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Drugs (e.g. OCP, steroids, pizotifen, sulphonylureas, insulin)

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Thyroid disorder (hypothyroidism) and other endocrine (as above)

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Is the patient trying to tell me something?

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Yes: the reasons for obesity should be explored.

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Key history

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Ascertain food and beverage intake including typical daily meals. Exercise, drug, psychological and family history.

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Key examination

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  • Measure body weight and height and calculate BMI, waist circumference, waist–hip circumference, upper arm circumference

  • Assess the degree and distribution of body fat and the overall nutritional status

  • Search for evidence of diabetes, atherosclerosis, hypothyroidism, Cushing syndrome and signs of alcohol abuse

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Key investigations

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These are more appropriate if patient unwell:

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  • anthropometric measurements as above, especially BMI and waist circumference

  • FBE

  • blood lipids

  • glucose (fasting)

  • LFTs

  • U&E

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Consider TFTs, serum cortisol, ECG and CXR.

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Diagnostic tips

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  • The onset of obesity can occur at any age.

  • Abdominal obesity gives a higher cardiovascular risk at any rate.

  • Ask the patient what they believe is the cause of their weight gain/obesity.

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