The role of the GP in the care of people with metabolic and endocrine problems
Good management of common metabolic and endocrine conditions can prevent or postpone associated morbidity and mortality. Additionally, certain conditions such as diabetes and obesity can be prevented through lifestyle and public health measures.
As a GP, your role is to:
- diagnose and manage common disorders such as diabetes mellitus, hyperlipidaemia, and thyroid and reproductive disorders
- recognise rarer and potentially life-threatening disorders such as Addison’s disease
- arrange and interpret appropriate biochemical tests for diagnosing and monitoring metabolic or endocrine disorders in a primary care setting
- understand and address the social, psychological and environmental factors underpinning living with obesity, diabetes and other metabolic and endocrine disorders
- understand the relationship between metabolic and endocrine disorders and other disorders such as cardiovascular disease, cancer, sleep apnoea, non-alcoholic fatty liver disease (NAFLD) and mental health problems
- coordinate care, encourage self-management and involve other agencies where appropriate
- recognise and manage metabolic and endocrine emergencies.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
Metabolic and endocrine diseases encompass a wide range of conditions, which may present with vague or non-specific symptoms, or no symptoms at all.
Symptoms and signs include (but are not limited to):
- changes in reproductive and sexual function such as menstrual irregularities, loss of libido, body hair changes and erectile dysfunction
- collapse and coma
- falls
- fractures
- gastrointestinal symptoms, for example nausea, vomiting, diarrhoea, constipation
- headache and visual problems
- high blood pressure
- joint pains and muscle problems
- mood changes
- polydipsia and polyuria
- pruritus
- skin changes
- thirst
- tiredness and lethargy
- weight gain or weight loss.
Common and important conditions
- Adrenal diseases, including Addison’s disease, Cushing’s syndrome, and disease, phaeochromocytoma, hyperaldosteronism, primary and secondary malignancy, adrenocorticotropic hormone (ACTH) secreting tumours, congenital adrenal hyperplasia
- Adverse metabolic effects of prescribed drugs (such as hypokalaemia with diuretics)
- Carcinoid syndrome, multiple endocrine neoplasia
- Type 1 and type 2 diabetes mellitus, maturity onset diabetes of the young (MODY), latent autoimmune diabetes in adults (LADA), gestational diabetes, pre-diabetes, impaired fasting glucose, impaired glucose tolerance and insulin resistance. In the context of these conditions, you should be aware of:
- diagnostic thresholds
- self-monitoring of glucose levels
- skin and eye manifestations, renal and neurological complications
- macrovascular complications and cardiovascular risk
- acute complications such as hypoglycaemia, diabetic ketoacidosis, non-ketotic hyperglycaemia
- lifestyle factor modification (for example, diet, physical activity, smoking)
- oral medication for diabetes management, including glucose and lipid-lowering therapies, antiplatelets, angiotensin-converting enzyme (ACE) inhibitors and antihypertensives; recommended treatment targets.
- injectable medications for diabetes management, including GLP-1 (glucagon-like peptide) agonists and insulin (regimes, administration and dosages)
- associations with other immunological conditions and types of cancer such as pancreatic cancer
- the effect of religious and cultural events on diabetes management, for example, Ramadan
- Disorders of calcium metabolism, including hypoparathyroidism, hyperparathyroidism and osteomalacia; association with chronic kidney disease and malignancy (such as bony metastases and myeloma)
- Disorders of sex hormones (for example, hirsutism, virilism, gynaecomastia, impotence, androgen deficiency, androgen insensitivity syndrome)
- Endocrine manifestations of non-endocrine diseases (such as bronchogenic carcinoma with inappropriate antidiuretic hormone (ADH) secretion)
- Haemochromatosis: primary and secondary, and other disorders of iron metabolism
- Hyperlipidaemias: familial and acquired
- Hyperprolactinaemia and its causes (for example, drug-induced, chronic renal failure, bronchogenic carcinoma, hypothyroidism, pituitary)
- Hyperuricaemia: primary and secondary (including haematological and drug-induced causes) and its associations with obesity, diabetes, hypertension and dyslipidaemia
- Hypothalamic causes of hormonal disturbances (for example, hyperprolactinaemia, drug-induced)
- Inherited metabolic diseases (such as phenylketonuria, glycogen storage diseases, porphyrias)
- Metabolic causes of unconsciousness (for example, hypoglycaemia, diabetic ketoacidosis, hyponatraemia, hypothyroidism, adrenal insufficiency)
- NAFLD, including its associations with diabetes, obesity and metabolic syndrome, and its consequences
- Osteoporosis
- Being overweight or living with obesity:
- assessment using parameters such as body mass index (BMI) and waist:height ratio. Interpret (including adjustment for specific ethnicities) and recognise limitations of these methods
- health consequences of obesity (including increased morbidity and reduced life expectancy)
- health promotion advice (including nutrition, smoking cessation and physical activity)
- pharmacological therapies for weight management
- risks and benefits of bariatric surgery
- direct and indirect impact of obesity on a wide range of diseases
- pituitary diseases, including acromegaly, primary and secondary hypopituitarism, and diabetes insipidus
- Poisoning (deliberate or unintentional), including by food, drugs (prescribed, over-the-counter or non-medicinal) or other chemicals
- Polycystic ovary syndrome (see also the Gynaecology and breast health topic guide)
- Psychogenic polydipsia
- Replacement and therapeutic intervention steroid therapy
- Thyroid diseases, including goitre, hypothyroidism, hyperthyroidism, benign and malignant tumours, thyroid eye disease, thyroiditis, neonatal hyperthyroidism and hypothyroidism:
- antibody testing, thyroxine replacement therapy and monitoring
- associations with other conditions, including cardiovascular disease
- potential for thyroxine abuse and strategies to reduce dosage
- Vitamin D deficiency, including its causes, health consequences and complications, testing and replacement therapy
Examinations and procedures
- Relevant focused examinations to identify features of common and important metabolic and endocrine conditions, underlying causes, manifestations of disease progression and associated conditions
- Specific examinations (such as assessment of neuropathy in diabetes, examination of a neck lump, visual field testing)
Investigations
- Common primary care tests to investigate and monitor metabolic and endocrine disease (for example, fasting blood glucose, HbA1c, urinalysis, urine albumin: creatinine ratio, ‘near-patient testing’ (point-of-care testing), lipid profile, thyroid function tests and uric acid)
- Other laboratory investigations, such as renal, liver, pancreatic, adrenal, pituitary, hypothalamic, ovarian and testicular function, antibody tests (for example, glutamic acid decarboxylase (GAD), thyroid antibodies)
- Normal biochemical parameters for common laboratory tests of metabolic and endocrine disease
- Imaging (such as a dual energy X-ray absorptiometry (DEXA) scan and interpretation) and tests of endocrine and metabolic dynamic function
- Screening of asymptomatic individuals to diagnose metabolic conditions (such as diabetes and pre-diabetes)
Service issues
- Screening tools and prevention programmes for conditions such as diabetes and osteoporosis
- Safe prescribing and medicines management, including approaches to polypharmacy, non-concordance with treatment and insulin therapy, and in women of childbearing age
- Early recognition, monitoring and evidence-based management of comorbidities, complications and cardiovascular risk in patients with conditions such as diabetes, obesity and thyroid disease
- Systems of care for people with metabolic or endocrine conditions, including primary and secondary care, voluntary sector organisations, shared care arrangements, multidisciplinary teams, patient involvement and structured education programmes
- Technology to improve practice and support collaborative care planning for people with long-term endocrine or metabolic conditions
- Key national policy documents influencing healthcare provision for people with metabolic or endocrine conditions
- Prescription charge exemptions for patients with certain conditions
- Population-based health interventions (such as exercise on prescription)
Additional important content
- Key guidance, for example from the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), and research findings (such as the UK Prospective Diabetes Study (UKPDS)) influencing the management of metabolic and endocrine conditions
- Associations between autoimmune diseases (such as diabetes, coeliac and thyroid diseases)
- Rare secondary causes of diabetes and thyroid disease (such as pancreatic disease, amyloid)
- ‘Sick day rules’ (for example, in diabetes, adrenal insufficiency)
- Genetic and environmental factors (such as ethnicity, lifestyle, social inequalities) affecting prevalence and outcomes in conditions such as diabetes
- Lifestyle interventions (including social prescribing) for conditions such as obesity, diabetes mellitus, hyperlipidaemia and hyperuricaemia
- Behaviour change consultation tools, such as motivational interviewing and Very Brief Advice (VBA) for smoking cessation
- Risk–benefit conversations with patients (including risks of complications)
- Risk calculation tools (for example, QRISK, QDiabetes)
- Psychosocial impact of long-term metabolic conditions on individuals and their wider social networks, such as the risk of depression and other mental health problems, sexual dysfunction, impact on employment and driving (including Driver and Vehicle Licensing Agency (DVLA) guidance)
- Indications for referral to an endocrinologist, metabolic medicine or other specialist
Case discussion
Charlotte Jones is 46 years old and has a BMI of 36. Despite numerous diets over the years, she has never managed to achieve sustained weight loss. She has a history of hypertension, hyperlipidaemia and type 2 diabetes mellitus that was diagnosed three years ago. Annual checks have identified background retinopathy but no evidence of nephropathy or neuropathy. Six months ago, she was started on insulin by the diabetes specialist team as her glycaemic control was poor on maximum oral hypoglycaemic therapy and she was due to undergo a cholecystectomy.
Unfortunately, her glycaemic control as measured by HbA1c has deteriorated further since starting insulin. Her blood pressure, cholesterol and triglycerides are elevated, and her weight has increased by 3kg over the last six months.
Charlotte is a single parent to two young children. She also looks after her elderly parents and works full time at a local bank. She has stopped driving, which she says is making life more stressful. You are concerned that she is not prioritising her health or coping with insulin injections.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are my own views about people who are overweight or living with obesity? How might my own views and societal attitudes to obesity influence how I care for patients who are overweight? What is unconscious bias? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | How would I explain to Charlotte the risks of complications from obesity or diabetes? Is there a risk of understatement or overstatement? What factors might influence this? As Charlotte’s GP, what is my legal responsibility in relation to her fitness to drive with diabetes? What is the General Medical Council (GMC) advice? What ethical issues may arise when sharing information within a multidisciplinary team? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | Have I explored Charlotte’s ideas, concerns and expectations? How can I communicate my concerns about her health? How could I approach health promotion in this case, or if the patient were a child, adolescent, pregnant or from an ethnic minority? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What potential emergencies may arise in this situation? How would I recognise a diabetic emergency? Does my GP practice have the appropriate equipment to diagnose and manage diabetic emergencies? What factors may affect the validity of an HbA1c value? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What clinical signs might I find in someone with poorly controlled diabetes? How confident am I in examining for diabetic neuropathy? Do I know how to use the blood glucose monitors and ketone meters in my practice? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | Why might Charlotte’s glycaemic control have deteriorated? How would I assess Charlotte’s cardiovascular risk? What else would I need to know to do this? How confident am I in giving nutritional advice, prescribing and altering medications in the care of diabetic patients? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | How can I demonstrate my ability to act as a team leader in this case? What drug and non-drug approaches might be used in this case? What factors might influence whether drug or non-drug management is used? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How would I explain to Charlotte the importance of managing her blood glucose, blood pressure, lipids and weight? What do I know about the benefits and harms of tight glucose control in diabetes? What targets should be aimed for in this case? How will I decide? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Which other professionals should be involved in this case? How do I liaise with them? How are diabetic patients managed in my practice? Who follows them up? What are the shared care protocols? How will I know whether Charlotte has attended her retinopathy screening or podiatry appointments? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What is the evidence base for current glycaemic, lipid and blood pressure targets in diabetes? What are the key national guidelines, frameworks, recommendations or quality standards relevant to this case (including the management of cardiovascular disease)? What is the guidance on diabetes management during Ramadan? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How would I audit the diabetic care in my practice? What standards and criteria would I use, and why? How would I use disease registers and data-recording templates in my practice to monitor diabetic patients and ensure continuity of care between primary care and other services? How does the practice receive and act on test results or feedback from secondary care? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What psychological, socio-economic and cultural factors might influence the health of this patient? Why? What questions should I ask to ascertain this? What barriers to good health care might Charlotte face (a) within the consultation and (b) more generally? How might the issues in this case impact on Charlotte’s family? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What is the local strategic approach to tackling obesity in my area, including non-NHS partners? What local, national and international public health interventions am I aware of to tackle obesity? What local initiatives exist to tackle health inequalities among people with conditions such as diabetes? What non-NHS organisations do I know of that might be relevant to this case? |
How to learn this area of practice
Work-based learning
Primary care is where the vast majority of patients with metabolic conditions present and are managed. Particular areas of learning in this setting include: prevention and risk factor management, communication and consultation tools to help people change health behaviours; acute and emergency management of metabolic problems; and chronic disease management, including surveillance for and early diagnosis of complications.
Some GP practices offer more specialised services in diabetes or obesity. Other arrangements may include intermediate diabetes care clinics. You will find it beneficial to attend some sessions.
Placements with acute diabetes or endocrinology specialists give GP registrars exposure to patients with serious metabolic or endocrine problems in the acute setting. Most specialist care is, however, provided in outpatient clinics and you should take the opportunity to attend specialist diabetes, endocrine and obesity clinics when working in other hospital posts and during your GP placements. This experience will enable you to learn about patients with uncommon but important metabolic or endocrine conditions (such as Addison’s disease and hypopituitarism), as well as about patients with complex needs or with complications of the more common metabolic conditions.
Particular areas of learning include: how to recognise metabolic or endocrine disorders that may be life-threatening if missed; which types of patient are best followed up by a specialist team; and when patients usually managed in primary care should be referred to a specialist team, including the timing and route of such referrals.
Self-directed learning
You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare and on the RCGP’s eLearning website.
Learning with other healthcare professionals
Achieving good outcomes in the management of chronic metabolic conditions such as diabetes requires well-organised and coordinated services that draw on the knowledge and skills of health and social care professionals. As a GP registrar you should attend nurse-led diabetes annual review assessments and participate in the follow-up of diabetic and other patients with metabolic or endocrine disease in primary care. You should take the opportunity to sit in with colleagues such as specialist diabetes or obesity nurses, dieticians and psychologists.
Structured learning
Some higher education institutions provide postgraduate certificate courses in diabetes, nutrition or metabolic problems. RCGP resources on diabetes, obesity and nutrition – including further qualifications – can be found in the learning and resources section of its website.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Drug management of type 2 diabetes
- Interpreting common electrolyte results
- Investigation of hypercalcaemia
Simulated Consultation Assessment (SCA)
- An airline pilot with type 2 diabetes is on maximum oral hypoglycaemic drugs and has an increasing HbA1c that is now 68 mmol/mol
- A young woman living with obesity is struggling to lose weight having tried a variety of different diets. Her recent blood results (provided) suggest polycystic ovary syndrome (PCOS)
- A middle-aged man attends to discuss a recent scan, arranged after blood tests showed mildly abnormal liver functions. The scan shows fatty infiltration of the liver
Workplace-based Assessment (WPBA)
- Consultation Observation Tool (COT) about a woman requesting levothyroxine to lose weight despite normal thyroid function
- Log entry about observing a patient being taught how to start insulin
- Clinical examination and procedural skills (CEPS) on examining a diabetic patient with neuropathy