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Rethinking hypercortisolism screening in obesity and diabetes: A systematic review and meta-analysis.
Davide Ferrari1, Ilaria Bonaventura1, Marta Tenuta2
1Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy.
Metabolism: Clinical and Experimental
|June 14, 2026
Summary
Hypercortisolism is often undiagnosed in patients with obesity and diabetes. Screening for conditions like Cushing
Area of Science:
- Endocrinology
- Metabolic Disorders
- Clinical Research
Background:
- Obesity and diabetes present a growing health burden, necessitating novel approaches for identifying secondary causes.
- Hypercortisolism, encompassing mild autonomous cortisol secretion to overt Cushing's syndrome (CS), may be underdiagnosed in these patient populations.
Purpose of the Study:
- To systematically assess the prevalence of hypercortisolism in individuals with obesity and/or diabetes.
- To evaluate the diagnostic utility of the dexamethasone suppression test (DST) as a screening tool.
- To inform potential reassessment of screening strategies for secondary causes of obesity and type 2 diabetes.
Main Methods:
- Systematic literature search of MEDLINE, Scopus, and Web of Science.
- Inclusion of studies reporting on hypercortisolism screening (primarily DST) and confirmed CS in obesity or diabetes cohorts.
- Data synthesis using random-effects models and assessment of evidence certainty with GRADE.
Main Results:
- 39 studies (14,995 participants) were included. In obesity cohorts (8705 individuals), abnormal DST prevalence was 4.6% and confirmed CS was 0.8%.
- In diabetes cohorts (6638 patients), abnormal DST prevalence was 14.3% (adjusted to 23.3%) and confirmed CS was 2.1%.
- Younger age, weight gain, and diabetes predicted CS. One in six abnormal DSTs led to CS confirmation. Evidence certainty was low to moderate.
Conclusions:
- Undiagnosed hypercortisolism is present in a significant subset of patients with obesity and diabetes.
- Further investigation is needed for individuals with abnormal DST results but without confirmed CS.
- Current screening strategies for secondary causes of obesity and type 2 diabetes may require re-evaluation.
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