Vitamin D

Screen those at high risk of vitamin D deficiency (e.g., limited or no sunlight exposure, individuals with obesity, osteoporosis, and malabsorption)

Vitamin D sufficiency is defined as a 25(OH) D concentration ≥ 30-100 ng/mL

• Vitamin D insufficiency is defined as a 25(OH) D concentration of 20 – 30 ng/mL
• Vitamin D deficiency is defined as a 25(OH) D level < 20 ng/mL
• A “risk” of vitamin D toxicity is defined as a 25(OH) D level >100 ng/mL in adults

Causes of vitamin D deficiency –

• Inadequate sunlight exposure
• Malabsorption
• Gastric bypass (bariatric surgery, gastrectomy)
• Pancreatic insufficiency
• Cirrhosis of liver
• Kidney failure
• Nephrotic syndrome
• Hyperparathyroidism
• Drug induced -Phenytoin

Vitamin B12

Causes of vitamin B12 deficiency –

• Vegetarian diet
• Drug induced (neomycin, metformin, omeprazole, pantoprazole, cimetidine etc.)
• Inflammatory bowel disease
• Malabsorption syndrome
• Fish tapeworm
• Bariatric surgery
• Autoantibodies to intrinsic factor or gastric parietal cells (pernicious anaemia)

For vitamin B12 deficiency, correction of the deficiency followed by routine supplementation is suggested.All individuals with vitamin B12 deficiency should have the cause determined.Some causes are reversible with treatment, and some causes require lifelong supplementation

Iron

Screen those at higher risk (e.g., premenopausal women, particularly those with prior pregnancies or heavy menstrual periods, as well as individuals with conditions that might cause blood loss or iron malabsorption).

Causes and risk factors for iron deficiency in adults-

1. Decreased intake

• Vegetarian or other diet with limited sources of iron

2. Decreased iron absorption-Helicobacter pylori infection

• Bariatric surgery
• Atrophic/autoimmune gastritis

3. Blood loss-

• Heavy menstrual bleeding
• Gastric ulcer disease or gastritis
• Colorectal cancer
• Surgical blood loss
• Gastrointestinal parasites
• Haemodialysis

Screening –

• For premenopausal females (particularly with prior pregnancies or heavy menstrual periods) and other individuals at increased risk.

Test

• CBC plus iron studies.
• For males and postmenopausal females – no screening

Anxiety

It is suggested to screen adolescents and adults ages 13 to 64 for anxiety disorders. Screening should use a validated instrument, such as the Generalized Anxiety Disorder-7 (GAD-7) scale.

Depression

It is suggested to screen adolescents and adults (ages 12 and older) for depression, including older adults.We suggest using a two-question screen or the Patient Health Questionnaire-2 (PHQ-2) because of ease of administration and reasonable sensitivity. A positive screen should be followed by a thorough clinical assessment, facilitated with the PHQ-9

Persons who screen positive are evaluated further for diagnosis and care.

Tobacco use

Smoking tobacco products is the most important risk factor for the development of lung cancer and contributes to other malignancies, cardiovascular disease, hypertension, stroke and pulmonary disease. Behavioural intervention and pharmacotherapy is available for quitting.

Alcohol –

• It is recommend that all adult patients be screened for unhealthy alcohol use.
• A useful tool is AUDIT-C
• Behavioural, psychiatric, social and medical manifestation of alcohol abuse –
• Anxiety, depression, sleep disorder
• Hypertension
• Gastrointestinal disturbance
• Liver dysfunction
• Cancer (oral, gastrointestinal, breast)
• Central/peripheral neurologic disorder
• Cardiac disorders
• Social/ legal problems.

Osteoporosis

Screening recommended for –

• All women ≥65 years.
• Postmenopausal women <65 years with risk factors*for osteoporosis
• Men with clinical manifestation of low bone mass, history of low trauma fracture, risk factors for fracture (such as androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, or intestinal disorders).

The most commonly used test is central dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine.

*Clinical risk factors for Osteoporosis –

• Advancing age
• Current cigarette smoking
• Excessive alcohol consumption
• Glucocorticoid therapy
• Low body weight
• Previous fracture
• Parental history of hip fracture
• Rheumatoid arthritis

Thyroid

All patients with symptoms and/or signs suggestive of hypothyroidism should be tested.Common symptoms of thyroid hormone deficiency include fatigue, cold intolerance, weight gain, constipation, dry skin, myalgia, muscle weakness, fatigue, menstrual irregularities Impaired memory, slowed mental processing and depression.

Screening in the absence of signs and/or symptoms of hypothyroidism — not routinely recommended. It is recommended to measure TSH in individuals who are at increased risk for hypothyroidism –

• Thyroid or neck surgery,
• Radioiodine therapy, external radiation therapy
• Hyperlipidaemia
• Hyponatremia,
• Macrocytic anaemia.
• High serum muscle enzyme concentrations.
• Pericardial or pleural effusions.
• Pituitary or hypothalamic disorders.
• History of autoimmune diseases.
• Malignancy treated with immunomodulatory therapy

Benefits of screening -The primary benefit of screening for hypothyroidism is the detection of hypothyroidism before the occurrence of symptoms.

Harms of screening – over diagnosis and overtreatment with thyroid hormone may be associated with adverse skeletal and cardiovascular effects.