Metabolic problems and endocrinology

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to endocrinology and metabolic problems by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources. See also: Topic Guide People with long-term conditions including cancer and Population health. 

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, 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 obesity, diabetes and other metabolic and endocrine disorders 
  • Understand the relationship between metabolic/ endocrine disorders and other disorders such as cardiovascular disease and cancer  
  • Coordinate care, encourage self-management, and involve other agencies where appropriate 
  • Recognise and manage metabolic and endocrine emergencies

Emerging issues in the care of people with metabolic and endocrine problems

GPs should understand the term 'pre-diabetes', including its diagnosis and management, and the growing significance of non-alcoholic fatty liver disease. You should also be aware of the increasing use of surgery in the management of obesity and diabetes, including its benefits and risks, and the role of the GP in post-surgery management. 

As people with metabolic or endocrine conditions live longer and become frailer, their medical needs may change. For example, older people with diabetes can face challenges such as difficulties with diagnosis, different glycaemic control targets, polypharmacy, and malnutrition. GPs should rationalise medication use wherever appropriate, thinking carefully about benefits versus potential harms. 

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 untreated condition, including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features  
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring and end-of-life care 
  • Patient 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/non-specific symptoms, or no symptoms at all. 

Symptoms and signs include (but are not limited to): 

  • Changes in reproductive and sexual function for example, 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
  • Symptom complexes and their characteristics 
  • Thirst 
  • Tiredness and lethargy  
  • Weight gain/weight loss 

Common and important conditions

  • Adrenal diseases including Addison's disease, Cushing's syndrome and disease, phaeochromocytoma, hyperaldosteronism, primary and secondary malignancy, ACTH secreting tumours, congenital adrenal hyperplasia 
  • Adverse metabolic effects of prescribed drugs (for example, hypokalaemia with diuretics) 
  • Carcinoid syndrome, multiple endocrine neoplasia 
  • Diabetes mellitus — type 1, type 2, and rarer types such as MODY (maturity onset diabetes of the young) and LADA (latent autoimmune diabetes in adults), pre-diabetes, impaired fasting glucose, impaired glucose tolerance, insulin resistance, gestational diabetes. 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) 
    • medication in diabetes management, including glucose and lipid lowering therapies, anti-platelets, ACE inhibitors and antihypertensives; recommended treatment targets; and 
    • insulin regimes, administration and dosages 
  • Disorders of calcium metabolism, including hypoparathyroidism, hyperparathyroidism and osteomalacia; association with chronic kidney disease and malignancy (for example, 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 (for example, bronchogenic carcinoma with inappropriate 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 (for example, phenylketonuria, glycogen storage diseases, porphyrias) 
  • Metabolic causes of unconsciousness (for example, hypoglycaemia, diabetic ketoacidosis, hyponatraemia, hypothyroidism, adrenal insufficiency) 
  • Non-alcoholic fatty liver disease (NAFLD), including its associations with diabetes, obesity and metabolic syndrome, and its consequences 
  • Osteoporosis 
  • Overweight and obesity
    • Assessment and classification using Body Mass Index (BMI), and limitations of this method 
    • Health consequences of obesity (including malnutrition, increased morbidity and reduced life expectancy) 
    • Health promotion advice (including nutrition, smoking cessation, physical activity) 
    • Pharmacological therapies for weight reduction 
    • Risks and benefits of bariatric surgery 
    • Direct and indirect impact of obesity on a wide range of disease areas 
  • Pituitary diseases including acromegaly, primary and secondary hypopituitarism, diabetes insipidus
  • Poisoning (deliberate or unintentional) including by food, drugs (prescribed, over the counter or non-medicinal) or other chemicals
  • Polycystic ovary syndrome (see RCGP Topic Guide Gynaecology and Breast Health) 
  • Psychogenic polydipsia 
  • Replacement and therapeutic steroid therapy 
  • Thyroid diseases including goitre, hypothyroidism, hyperthyroidism, benign and malignant tumours, thyroid eye disease, thyroiditis, neonatal hyper- and hypo-thyroidism: 
    • 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/complications, testing, and replacement therapy

Examinations and procedures 

  • Relevant focused examinations in order to identify: features of common and important metabolic/endocrine conditions, underlying causes, manifestations of disease progression, and associated conditions 
  • Specific examinations (for example, assessment of neuropathy in diabetes, examination of a neck lump, visual field testing)

Investigations 

  • Common primary care tests to investigate and monitor metabolic/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, GAD, thyroid antibodies) 
  • Normal biochemical parameters for common laboratory tests of metabolic/endocrine disease 
  • Imaging (for example, DEXA scan and interpretation) and tests of endocrine and metabolic dynamic function 
  • Screening of asymptomatic individuals to diagnose metabolic conditions (for example, 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, insulin therapy, and in women of childbearing age 
  • Early recognition, monitoring and evidence-based management of co-morbidities, complications, and cardiovascular risk in patients with conditions such as diabetes, obesity and thyroid disease 
  • Systems of care for people with metabolic/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/endocrine conditions 
  • Prescription charge exemptions for patients with certain conditions 
  • Population-based health interventions (for example, exercise on prescription)

Additional important content 

  • Key guidance (for example, NICE, SIGN) and research findings (for example, UKPDS) influencing the management of metabolic/endocrine conditions  
  • Associations between autoimmune diseases (for example, diabetes, Coeliac and thyroid disease) 
  • Rare secondary causes of diabetes and thyroid disease (for example, pancreatic disease, amyloid) 
  • ‘Sick day rules’ (for example, in diabetes, adrenal insufficiency) 
  • Genetic and environmental factors (for example, 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, 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 (for example, the risk of depression and other mental health problems, sexual dysfunction, impact on employment and driving (including DVLA guidance)) 
  • Indications for referral to an endocrinologist, metabolic medicine or other specialist. 

Case discussion

Mrs Jones is 46 years old with 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 maximal 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 3 kg over the last six months.  

Mrs Jones 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 Competence   
                      Questions                   

Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

What are my own views about overweight and obesity?  

How might my attitude and societal attitudes to obesity influence how I care for patients who are overweight?  

What is unconscious bias? 

Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

 

 

How would I present to Mrs Jones the risks of complications from obesity or diabetes? Is there a risk of under- or overstatement? What factors might influence this? 

As Mrs Jones' GP, what is my legal responsibility in relation to her fitness to drive with diabetes? What is the GMC's advice?  

What ethical issues may arise when sharing information within a multidisciplinary team? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

Have I explored Mrs Jones' ideas, concerns and expectations?  

How can I communicate my concerns about her health? 

How could I approach health promotion in this case? And if the patient were a child, adolescent, pregnant, or from an ethnic minority? 

Data gathering and interpretation 
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

What potential emergencies may arise in this situation? 

How would I recognise a diabetic emergency? Does my surgery 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 the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 

 

 

 

What clinical signs might I find in someone with poorly controlled diabetes? 

How confident am I in examining for diabetic neuropathy? 

Do I know to use the blood glucose monitors/ketone meters in my practice? 

Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

Why might Mrs Jones' glycaemic control have deteriorated? 

How would I assess Mrs Jones' cardiovascular risk? What else would I need to know to do this? 

How confident am I to give nutritional advice, prescribe and alter medications in the care of diabetic patients? 

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

 

How can I demonstrate my ability to act as a team leader in this case? 

What drug and non-drug approaches might be adopted in this case?  

What factors might influence whether drug or non-drug management is adopted? 

Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

How would I explain to Mrs Jones 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?

Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

 

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 Mrs Jones has attended her retinopathy screening or podiatry appointments?  

Improving performance, learning and teaching 
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

 

 

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? 

Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management 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? 

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

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 Mrs Jones face (a) within the consultation and (b) more generally? 

How might the issues in this case impact on Mrs Jones' family? 

Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

 

 

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 trainees 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 patients 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 e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare and on the RCGP's elearning site.  

Learning with other health care professionals 

Achieving good outcomes in the management of chronic metabolic conditions such as diabetes requires well-organised and co-ordinated services that draw on the knowledge and skills of health and social care professionals. As a specialty trainee you should attend nurse-led diabetes annual review assessments and participate in the follow-up of diabetic and other patients with metabolic/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 Clinical resources section.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • DVLA regulations for diabetes
  • Symptoms of acute Addisonian crisis  
  • Pituitary hormone test interpretation 

Clinical Skills Assessment (CSA) 

  • Airline pilot with type 2 diabetes is on maximum oral hypoglycaemic drugs and has an increasing HbA1c which is now 68 mmol/mol 
  • Obese young woman is failing to lose weight on a variety of different diets. Her recent blood results (provided) suggest PCOS 
  • Middle aged man attends to discuss a recent scan, arranged after blood tests showed mildly abnormal LFTs. 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

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