Which is the most likely diagnosis ? |
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micronutrients to promote safe and effective weight loss . 1 – 3 VLED meal replacements are usually taken in the form of a commercial powdered liquid formulation . They contain a mix of carbohydrate , fat and protein and are usually deemed nutritionally complete if used as a sole source of nutrition . 1 , 2 VLEDs are designed to promote significant weight loss , specifically of fat mass , while maintaining lean body mass . 1 , 2 , 4 Individuals are often prescribed a VLED for 2-4 months . 1 , 2
The body stores carbohydrate as glycogen within the liver or muscle cells — sufficient to provide energy for approximately three days . 5 In a state of starvation or dietary restriction of carbohydrate , glycogen stores are depleted and energy stored as fat in adipose tissue is mobilised and converted to ketones . 5 , 6 Ketosis describes the metabolic state where the body utilises ketones for energy instead of glucose . A particular advantage of VLEDs is their ability to induce mild nutritional ketosis . 1 , 5 Through significant energy restriction , VLEDs consequently restrict carbohydrate intake , usually to 50-70g a day . 7
VLEDs and ketogenic-low carbohydrate diets are frequently marketed as highly effective weight-loss interventions because of their ability to suppress appetite . Appetite suppression is thought to be achieved in a state of ketosis . 5 – 8 While clinical trials investigating the impact of ketosis on appetite suppression have been inconsistent , encouragingly , individuals adhering to a VLED or ketogenic-low carbohydrate diet have reported increased satiety and reduced desire to eat while in a state of energy restriction . 8
Increased appetite resulting from energy restriction for weight loss is one of the most significant limiting factors to success . Thus , achieving ketosis , and preventing a state of hunger that is frequently experienced in dietary restriction approaches to weight loss , is likely to make a significant practical difference to individuals . 8
An additional advantage of utilising a VLED meal replacement program is convenience . 9 Greater compliance has been demonstrated in individuals using meal replacements compared with those following conventional weight-loss programs . 9 The transition from the initial or intensive phase of a VLED to the reintroduction of conventional foods is challenging and requires planning and support . 10 It is recommended to gradually wean VLED meal replacements and instead include specified meals — typically comprised of low-fat and reduced-carbohydrate foods . 1
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Table 1 . Susie ’ s usual meals
Breakfast
Lunch
Dinner
Cheese and tomato toastie OR cornflakes with milk
Takeaway sweet and sour chicken OR takeaway beef burrito OR baked beans on toast
Pasta bake OR fish fillets with roast potato and vegetables OR steak with pepper sauce , hot chips and salad
Drinks Water , coffee with milk and sugar x2 , occasional glass of cordial
Snacks
Sweet biscuits , fresh fruit , dip and crackers
Box 2 . Susie ’ s anthropometry and body composition results after four months
Weight ( kg ) 101
Height ( m ) 1.59
BMI ( kg / m2 ) 39.9
Fat mass ( kg ): 48.3
Muscle mass ( kg ) 50.1
Body fat (%) 48
Waist ( cm ) 97
Outcome
Susie is reviewed by the dietitian every two weeks after starting the VLED . During this time , Susie does not report feeling hungry at all . She does report sometimes missing habitual and comfort eating but is able to counteract this by trying to increase her step count . When initially following the VLED , Susie did experience constipation , which she effectively managed with fibre supplementation .
After four months of VLED adherence and increased movement , Susie has lost 23kg ( 18.5 % body weight ), of which 21.4kg was fat mass . Box 2 shows Susie ’ s progress anthropometry and body composition results . She also has minimal loss of lean body mass . The dietitian works with Susie to plan a gradual transition from the VLED , focusing on including whole foods and limiting added sugars to moderate dietary fat and carbohydrate intake .
References on request from kate . kelso @ adg . com . au
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Increased appetitie as a result of energy restriction is one of the main factors that limits success for people trying to lose weight .
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a Atopic dermatitis
b Discoid lupus erythematosus
c Dermatophytosis
d Cutaneous metastatic breast cancer
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ANSWER The answer is b . Discoid lupus erythematosus ( DLE ) is the most prevalent form of cutaneous lupus erythematosus . 1 It is a chronic inflammatory disorder initially characterised by erythematous macules and papules that typically evolve into discshaped scaly plaques . 1 The rash is often asymptomatic , but can be pruritic and sore .
DLE is mostly localised ( above the neck – 80 %), but can be generalised ( below the neck – 20 %). 1 It may progress into areas of hyperpigmentation with central atrophic scarring alongside hypopigmentation and telangiectasia . Scarring alopecia is common in affected hair-bearing areas .
DLE may occur due to endogenous factors , such as genetic predisposition , and may be aggravated by exogenous factors , including smoking and UV light exposure . It is more likely to occur on sun-exposed areas . 2 It is most commonly seen in women aged 20-40 , although both genders may be affected at any age . The condition is becoming increasingly common and severe in people of colour , especially Indigenous Australians and those of South-East Asian descent . In people of colour , hyper- and hypopigmentary change is more pronounced . 3
Diagnosis is based on clinical examination , lesional skin biopsy and blood tests , including full blood count , kidney function , antinuclear antibodies ( ANA ), and extractable nuclear antigen ( ENA ). ANA and ENA are negative in 85 % of patients with DLE , unlike subacute and systemic lupus erythematous , in which these markers are more likely to be positive . 4
Treatment includes photoprotection using sun-protective clothing , hats and sunscreen . Limited disease may be treated with topical corticosteroids or calcineurin inhibitors , with intralesional corticosteroid injection an option for escalation . More extensive or treatment-resistant disease warrants dermatology input and may require systemic therapy with hydroxychloroquine , immune response modifiers ( such as sulfasalazine or biologics ) or immunosuppressants ( such as systemic steroids , azathioprine or methotrexate ). For patients under consideration for hydroxy chloroquine therapy , it is recommended to refer for screening for retinopathy ( due to increased risk of this with higher hydroxychloroquine doses ) and G6PD deficiency ( in which case this agent is contraindicated ).
Atopic dermatitis typically affects flexures . Dermatophytosis is less likely given the lack of improvement with antifungal therapy , and lack of characteristic ring-shaped lesions . Cutaneous metastatic breast cancer classically presents as firm , rubbery nodules over the breast and ipsilateral chest wall . References on request from kate . kelso @ adg . com . au
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