⚖️ Unintentional or persistent weight gain can result from lifestyle, medical, psychological, or endocrine causes. 📈 It is important to distinguish between increased adiposity (fat gain), fluid retention (e.g., heart failure), and secondary causes (e.g., endocrine disorders). 🔍 A systematic approach ensures reversible and serious causes are not missed.

🩺 Clinical History

⏱️ Onset & Duration: Gradual vs sudden gain.
🍔 Dietary History: Appetite changes, portion sizes, snacking, sugary drinks.
🏃 Physical Activity: Sedentary behaviour vs regular exercise.
📜 Medical History: Hypothyroidism, Cushing’s, PCOS, diabetes, heart failure. Review medications (steroids, antipsychotics, antidepressants, anticonvulsants).
🧠 Psychosocial Factors: Stress, mood changes, emotional eating, sleep disruption.
👨‍👩‍👧 Family History: Obesity, metabolic syndrome, type 2 diabetes.

👩‍⚕️ Physical Examination

👀 General Inspection: Distribution of fat (central vs peripheral), striae, skin changes.
📈 Vitals: BP, HR, temperature (look for hypertension, Cushing’s features).
📏 Anthropometrics: - Body Mass Index (BMI). - Waist circumference (central obesity = ↑ metabolic risk).
Systematic Examination: - Endocrine: goitre, dry skin (hypothyroidism), moon face, buffalo hump (Cushing’s). - Cardiovascular: peripheral oedema, raised JVP (CHF).

🔬 Investigations

🧪 Blood Tests: - Thyroid function (TSH, T4) - Fasting glucose & HbA1c (diabetes/insulin resistance) - Lipid profile (dyslipidaemia) - LFTs (fatty liver disease) - Cortisol (if Cushing’s suspected)
🖥️ Imaging: Abdominal ultrasound for NAFLD; CT/MRI for adrenal/pituitary pathology.
🧠 Psychological Assessment: Depression, anxiety, eating disorders (binge eating disorder).

📚 Causes of Weight Gain

🧬 Endocrine: Hypothyroidism, Cushing’s, PCOS, metabolic syndrome, insulin resistance.
💊 Medications: Antidepressants, antipsychotics, corticosteroids, valproate.
🧠 Psychological: Depression, anxiety, stress eating, binge eating disorder.
🍟 Lifestyle/Dietary: High-calorie diet, low activity, sedentary work.
❤️ Chronic disease/fluid retention: Heart failure, CKD.
👨‍👩‍👧 Genetic/familial: Obesity tendencies, syndromes (Prader-Willi).

⚕️ Management

🎯 Treat underlying cause: e.g., levothyroxine for hypothyroidism, surgery/medical therapy for Cushing’s.
🥗 Lifestyle modification: Diet quality, calorie balance, reduce processed food/sugar intake.
🏃 Physical activity: Tailored to patient ability — aim 150 mins moderate activity/week.
🧠 Behavioural support: Dietitian, CBT, group weight management programmes.
📈 Monitoring: Weight, waist circumference, BMI, metabolic risk factors (BP, HbA1c, lipids).

📊 Summary Table

Cause	Investigations	Management
Hypothyroidism	TFTs, thyroid antibodies	Levothyroxine, monitor TFTs
Cushing’s Syndrome	24-hr urinary cortisol, dexamethasone suppression, ACTH, pituitary/adrenal imaging	Adrenalectomy/pituitary surgery, cortisol-blocking drugs
PCOS	Hormone profile, pelvic ultrasound, glucose tolerance	Lifestyle, metformin, hormonal contraception
Heart Failure	Echocardiogram, BNP, CXR, ECG	Diuretics, ACE inhibitors, fluid/salt restriction
Medication-related	Medication review, BMI monitoring	Adjust/switch agent, add lifestyle support
Psychiatric Disorders	Psychiatric assessment, PHQ-9, GAD-7	CBT, antidepressant switch, lifestyle therapy
Genetic/Syndromic	Genetic testing, hormonal profile	Behavioural therapy, dietary control, growth hormone therapy (e.g., Prader-Willi)
Lifestyle/Overeating	Food diaries, physical activity logs, BMI	Dietary changes, physical activity, structured weight-loss programme

💡 Teaching Pearls

📏 Central obesity (↑ waist circumference) is a stronger predictor of cardiovascular risk than BMI alone.
🧠 Screen for psychological contributors — weight gain can be secondary to mood disorders or stress.
⚖️ Distinguish fat gain vs fluid retention (important in CHF, nephrotic syndrome).
🚨 Rapid weight gain = think endocrine or fluid overload, not lifestyle alone.

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Weight Gain Adults